DS13. Anticipatory or “Just in Case” Medicines in Domiciliary Care
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Anticipatory or “Just in Case” Medicines in Domiciliary Care Policy
Background
{{org_field_name}} understands that anticipatory medicines are those intended for prompt relief of distressing symptoms for a person who is receiving palliative care for a terminal illness. Anticipatory medicines, which will usually include controlled drugs, will be most frequently used in the last stages of a person’s life. The medicines are made available in advance of their need so that they can be accessed as soon as they are needed.
The medicines will usually be prescribed by the person’s GP or nurse practitioner, for use during the out-of-hours periods when access to the patient’s own general practice and regular pharmacy may not be possible, but immediate relief is required. Anticipatory medicines could cover a range of terminal illnesses or potentially fatal conditions, notably cancer, but also heart, neurological and respiratory conditions.
Anticipatory medicines typically include medication given for pain relief, for sickness or nausea, or for anxiety or restlessness. They are sometimes referred to as “Just in Case” medicines.
Guidance
Quality standard QS144 Care of dying adults in the last days of life, published by the National Institute for Health and Care excellence (NICE), includes guidance on the use of anticipatory prescribing.
Quality statement 3 states that adults in the last days of life who are likely to need symptom control are prescribed anticipatory medicines with individualised indications for use, dosage and route of administration.
The standard was published to support NICE guideline NG31 Care of dying adults in the last days of life (2015).
Policy Statement
It is understood that anticipatory prescribing will make sure that there is a supply of suitable medicines or drugs in the ill person’s home with any equipment needed to administer them. They can then be made available to an attending medical practitioner or someone who is authorised to administer them after it has been clinically assessed that they should be given.
{{org_field_name}} recognises that according to NICE guidance (NG31):
- an individualised approach should be used by prescribers for making anticipatory medicines available for people who are likely to need symptom control in the last days of life
- the prescriber should assess the medicines that a person might need to manage symptoms such as agitation, anxiety, breathlessness, nausea and vomiting, noisy respiratory secretions and pain, taking into account the likelihood of specific symptoms occurring
- prescribing needs should be discussed with the dying person, with those important to them and with the multi-professional team
- indications for use and the dosage of any medicines prescribed should be specified.
NICE further recommend that, before anticipatory medicines are administered, the dying person’s individual symptoms should be reviewed and their individualised care plan and prescriptions adjusted as necessary.
Once prescribed, the medicines belong to the patient and have the same legal status as other prescribed medicines, including controlled drugs.
It is understood that anticipatory medicines are usually supplied in specially marked containers, commonly called “just in case” boxes. The provision of such boxes usually provides good opportunities to discuss with the ill person and others involved in their care the likely process of the illness that could result in their use.
The contents of “just in case” boxes will be decided in terms of individual needs and local agreements and protocols for prescribers and pharmacists. The protocols should indicate such things as:
- the normal starting doses and how they will be made known to users
- the contents of the boxes
- the quantities to be supplied
- their duration with reference to expiry dates, after which unused medicines will need to be disposed of
- who should be notified of their having been prescribed
- who is authorised to administer them
- their storage and security, pending use.
Implications for a Domiciliary Care Service
Anticipatory medicines in the form of “just in case” boxes might be prescribed when a person prefers to spend their final days in their own home and it has been planned that they should do so with the appropriate care and support.
It is understood that the medical practitioners involved in a person’s end-of-life care will be responsible for the prescribing and oversight of any anticipatory medicines and for authorising their use. The person using the services and immediate carers will be responsible for their safe storage and security in the home in line with medical guidance and advice.
{{org_field_name}} will note and record that the medicines have been prescribed for the individual person and the details will be recorded on their care plan. It will then report to the responsible medical practitioners any changes in the person’s condition that could result in permission for the medication to be used.
The end-of-life care plan should state which medicines have been prescribed and under what circumstances they will be used and by whom. {{org_field_name}} will then follow the requirements of the care plan.
Its staff might or might not be directly involved in any of the arrangements made for their availability and use but they would expect to be made aware of them and the rules governing their use. They could then be expected to report in line with their duty of care if they observed or knew of any mismanagement or breaking of the agreements that might have adverse effects on the ill person’s state of health; taking into account that the anticipatory medicines are likely to include controlled drugs that have attendant risks.
The end-of-life care plan should also include any precautions to be taken in relation to any risks involved in their administration, which could have an impact on the roles and responsibilities of {{org_field_name}}’s staff in what is likely to be a multidisciplinary undertaking.
{{org_field_name}} understands that the medicines will be stored in a secure box or container in a safe place, which should only be opened by a named authorised person or persons when they are needed and after a clinical assessment that they should be used (for example, by a GP or nurse with due authority).
If (unusually) it has been agreed that a care service staff member should be authorised to use them when needed following a clinical assessment (for example, with this use co-ordinated with a GP by telephone) it must be established in advance that they are competent and trained to use the required medicines and understand the circumstances in which they will be used.
Training
Staff involved in the end-of-life care of a person will be instructed in the purpose and use of any “just in case” medicines and the protocols associated with their administration for the named person.
Care service staff who have been authorised to administer any of the anticipatory medicines will receive specialised training to be specifically competent in their use.
Responsible Person: {{org_field_registered_manager_first_name}} {{org_field_registered_manager_last_name}}
Reviewed on: {{last_update_date}}
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