Community-based anticipatory prescribing during COVID-19: a qualitative study

Abstract

ObjectivesTo understand healthcare professionals’ experiences of delivering anticipatory prescribing (AP) during the first wave of the UK COVID-19 pandemic.MethodsSemistructured qualitative interviews were conducted with a purposive sample of 16 healthcare professionals involved in community palliative care. Data were analysed inductively using thematic analysis.ResultsSome of practitioners’ fears about the pandemic’s impact on delivering AP had not been realised during the first wave. Among patients with COVID-19 for whom community end-of-life care was deemed appropriate, deaths were perceived to be relatively easy to palliate with standard medications. These deaths were typically too rapid for AP to be appropriate or feasible. For non-COVID deaths, providing timely AP was more challenging: although community nurses and some palliative specialists continued to visit patients regularly, general practitioners did many fewer visits, moving abruptly to mainly remote consultations. This left some community nurses feeling undersupported, and prompted some palliative specialists to increase their direct involvement in AP. Several other changes were widely welcomed: collaboration to maintain drug supplies, adoption of online meetings and paperless practice, enhanced specialist helplines and a new policy allowing reuse of medication in care homes. The inclusion of more non-injectable options in AP protocols allowed clinicians to offer selected patients more choice, but few had yet done this in practice. No participants reported changing their prepandemic practice regarding administration of AP by lay caregivers.ConclusionsAccomplishing AP during a pandemic was challenging, requiring healthcare professionals to make rapid changes to their systems and practices. Some changes may produce lasting improvements.

Simultaneously reassuring and unsettling: a longitudinal qualitative study of community anticipatory medication prescribing for older patients

“…The most striking finding was the variable and often vague nature of recalled conversations with clinicians about the process of dying and the role of anticipatory medication in planned care. The arrival of medication with limited or no prior discussions may reflect the reduction in the numbers of GP home visits during the Covid-19 pandemic, with consultations and prescriptions been done remotely [ 22 , 31 , 32 ]. However, remote prescribing based on district nurses and palliative care team recommendations regularly occurred before the pandemic [ 3 , 13 , 33 ].…”

“…Informal caregivers also expressed ambivalence regarding the helpfulness of anticipatory medications in controlling symptoms and had concerns about their safety [ 18–20 ]. Older patient and informal caregiver experiences of anticipatory medications, and their preferences for involvement in decision-making, are of critical importance and warrant more detailed investigation [ 13 , 18 , 21 , 22 ].…”

Anticipatory prescribing in community end-of-life care: systematic review and narrative synthesis of the evidence since 2017

“…13 14 The intervention has become an embedded part of symptom control care and is widely perceived by clinicians and policymakers to be a key end-of-life clinical intervention. [15][16][17][18][19][20] However, two UK independent reviews into the mismanagement of injectable medications have raised serious concerns about inappropriate practices in prescribing and using anticipatory medications. 21 22 Four years ago, we systematically reviewed and synthesised evidence supporting the practice of anticipatory prescribing for dying adults in the community, and found that it has been founded on an inadequate evidence base.…”

“…Patient and family caregiver experiences of anticipatory prescriptions and their involvement in decisions to administer medication with nurses require urgent investigation. 20 25 47 62 This was also a key recommendation from the original systematic review findings; this priority area has still received inadequate research attention, possibly due to ethical concerns about interviewing dying patients and their families. Recent published research has focused primarily on the views of bereaved family caregivers of patients who received specialist palliative care [50][51][52] ; many patients and families do not receive this level of specialist input and care, and may have diverse experiences.…”