The use of a syringe driver to administer drugs by continuous subcutaneous infusion is common practice in the UK. Over time, drug combinations used in a syringe driver are likely to change and the aim of this survey was to obtain a more recent snapshot of practice. On four separate days, at two-week intervals, a questionnaire was completed for every syringe driver in use by 15 palliative care services. Of 336 syringe drivers, the majority contained either two or three drugs, but one-fifth contained only one drug. The median (range) volume of the infusions was 15 (9.5-48) mL, and duration of infusion was generally 24 hours. Only one combination was reported as visually incompatible, and there were 13 site reactions (4% of total). Laboratory physical and chemical compatibility data are available for less than half of the most frequently used combinations.
Transdermal fentanyl patches first became available in the early 1990s and provided an innovative treatment for the management of cancer pain. Since then, they have become a familiar and convenient method for providing analgesia for patients with stable levels of cancer pain. Transdermal delivery is more complex than oral administration and some specific factors need to be taken into consideration for the patches to be used appropriately and to their best advantage. This article will review the use of transdermal fentanyl, looking at their place in the overall therapy plan, the use of appropriate adjunctive prescribing and some specific practical and safety issues.
The Gold Standards Framework for Care Homes [GSFCH] and the Liverpool Care Pathway [LCP] guidance suggests the importance of obtaining anticipatory medication for the control of symptoms in the last days of life for nursing home (NH) residents. There is considerable wastage however as NH residents are dispensed anticipatory drugs on a named-patient basis. There is also evidence that when these drugs are not available residents are hospitalised inappropriately.
Aim
The aims of the project were to explore the frequency of symptoms experienced in the dying phase and to explore whether there was a need for residents to have their own supply of drugs by examining wastage. The idea was to establish a process in order for homes to obtain anticipatory medication as ‘stock’ and to capture the benefits of doing this.
Process
The managers of three NHs, who had shown interest in obtaining medication for the last days of life, met with a local GSFCH facilitator, specialist palliative care pharmacist and a pharmacist from the regulatory body. A proposal that included a list of necessary medication and how to acquire them was written. The NH staff developed the required Standard Operating Procedures. A prospective audit on medication used was commenced.
Results
Significant improvements in the availability of anticipatory medication were found. 53% of residents were symptomatic highlighting the need to have anticipatory medication available. No medication other than “stock” was required by NHs. If all residents had their own supply of medication £4,506 worth of drugs would have been wasted. All staff involved perceived that this work had been beneficial.
Conclusion
Anticipatory medication ‘as stock’ for people dying in NHs is an important step forward. There is less wastage of medication, less delay in controlling symptoms, reduced call out of GPs and less anxiety.
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