New approaches to ease pain and suffering in end-of-life community care are needed, according to a paper published this week in the BMJ.
Researchers, led by Dr Ben Bowers at Cambridge University Primary Care Unit, highlighted four new additional options to ensure fast access to medications for patients in their last few days and hours of life., including 24-hour, seven days a week rapid access to medicines through pharmacies, care homes and paramedics.
Patients dying in the community require rapid and tailored access to last days of life medications. This can be difficult to organise despite the pain and stress these medications can alleviate. Most end-of-life medications are needed during out-of-hours periods, and sourcing medical assessments, prescriptions and drugs from pharmacies can be challenging.
End-of-life anticipatory prescribing is currently recommended as good practice. It involves prescribing injectable drugs, including opioids and sedatives, for five common symptoms: pain, breathlessness, nausea and vomiting, agitation, and noisy respiratory tract secretions. The drugs are kept in patients’ homes and are available for use by visiting nurses, doctors, paramedics or trained family carers, but up to 54 per cent of anticipatory drugs go unused.
The researchers state that ‘improved review, provision, and personalisation of medication is needed’ and suggest four additional options to optimise rapid access to anticipatory medications and to reduce wastage.
The first suggestion includes resourcing more community pharmacies to supply end-of-life medications 24 hours a day, seven days a week.
Second, the researchers suggest that emergency paramedics should be allowed to carry end-of-life drug stocks to administer to dying patients, following authorisation and consultation with a remote senior clinician.
Third, healthcare services and nursing homes should hold stock of end-of-life medications that can be dispensed rapidly following a prescription.
And a fourth option would involve changing pharmaceutical regulations to permit end-of-life medications prescribed for one care home resident to be repurposed for another resident, following a medical assessment and individualised prescription. This was allowed during the Covid-19 pandemic and according to the researchers was ‘widely welcomed’.
The last two options would require changes in legislation and appropriate safeguards in many countries.
The researchers conclude that proposed changes ‘will need careful piloting and robust evaluation of their clinical effectiveness, safety, and unintended consequences’, as well as consideration of patients’ and families’ views. And when taken together, the new options could ‘considerably reduce medication wastage but most importantly help to avoid preventable suffering in the final days and hours of life’.