POLICY FOR ANTICIPATORY PRESCRIBING FOR PATIENTS WITH A TERMINAL ILLNESS Just in Case

POLICY FOR ANTICIPATORY PRESCRIBING FOR PATIENTS WITH A TERMINAL ILLNESS Just in Case DOCUMENT NO: DN116 Lead author/initiator(s): Sarah Woodley Community Health Services Pharmacist sarah.woodley@ccs.nhs.uk Developed by: Originally developed in Cambridge City and South Cambridgeshire PCT by Sarah Woodley and Dr Angela Steele GP Macmillan Facilitator in March 2007. Updated by the Palliative Care Policy task and finish group in Cambridgeshire Community Services in 2008 and 2010. Version 3 has been updated and harmonised across the Trust by Sarah Woodley in consultation with the Pan Cambridgeshire Palliative Medication Task and Finish Group, November 2012. Approved by: Cambridgeshire Community Services NHS Trust Medicines Safety and Governance Group Approval date: 17 th December 2012 Review date: December 2014 Version no: 4 For office use only: Ratified by: (enter Board of Directors or Sub-committee of BoD) Date ratified: 18 January 2013 Version Control And Revisions: Quality Improvement and Safety Committee 1 First published for CCS NHS Trust March 2008 Version Page/Para No. Description of change Date approved 2 October 2009 3 Whole document Reformatted and rearranged with minor September 2010 amendments to text with no change in meaning. Changed references to PCT and CCS to refer to CCS NHS Trust. 1.0 Introduction Referred to Department of Health End of Life care Strategy, 2008. Combined aims and objectives into one Policy for Anticipatory Prescribing for Patients with a Terminal Illness Just in Case Page 1 of 12

2.0 Objectives 3.3 Responsibilities 5.1 Process paragraph. Changed telephone number for ordering bags, leaflets and charts Included recommendation that medicines are prescribed in a quantity that can be dispensed in the manufacturer s original pack where possible. Added that recommended brand for sublingual lorazepam (Genus) and a note that this is unlicensed method of use. Included details of how medicines should be prescribed on the prescription chart. Included midazolam (Schedule 3 CD) 5.3 Managing in Just in case bag in the home 5.4 Administration from the bag 5.5 Disposal 6. Risk Management 7. Training Appendices Added reference to the new Controlled Drug Balance Record Form for Domiciliary Use. Added that the nurse must also record midazolam (Schedule 3 CD) Amended to The nurse must check the contents of the Just in Case bag after one week and carry out a risk assessment for each individual patient to decide how often the just in case medicines need to be checked, this must be documented. The Just in Case medicines must be checked at least once every 4 weeks. Amended to if the nurse cannot account for all of the controlled drugs, after enquiry with the family and healthcare team, the team leader must inform the Accountable Officer and complete an incident form. Added: The nurse must reassess / review the frequency of checks in accordance with the patient s needs. Amended to a family member should return all medicines to a community pharmacy or dispensary Added that medicines must not be returned to stock Included reference to NPSA alert on reducing dosing errors with opioid medicines Reference to audit undertaken. Added every member of the healthcare team has a responsibility to check that the intended dose of an opioid medicine is safe for the individual patient. When opioid medicines are prescribed, dispensed or administered, the healthcare practitioner concerned should be familiar with the usual starting dose, frequency of administration, standard dosing increments, symptoms of overdose and common side effects. Removed leaflets (these will be available separately on the CCS NHS Trust website) and audit form. 4 Policy Harmonisation across the Trust December 2012 THIS IS A CONTROLLED DOCUMENT Page 2 of 12

Whilst this document may be printed, the electronic version maintained on the CCS NHS Trust Intranet is the controlled copy. Any printed copies of this document are not controlled. Cambridgeshire Community Services NHS Trust. Not to be reproduced without written permission. Page 3 of 12

DOCUMENT CONTROL SHEET Purpose of document: Dissemination: Implementation: Review: This document supports: Key related documents: Equality & Diversity: Financial Implications: Contact point for queries: Key word search To provide a safe framework for anticipatory prescribing and administration of medicines for patients with a terminal illness in line with national guidance, legislation and best practice. This policy replaces the Cambridgeshire Community Services Policy for Anticipatory Prescribing in Patients with a Terminal Illness Sept 2010 Available on the Trust intranet and external website link All healthcare staff in the Trust will be informed via the Communication Cascade Other individuals / organisations will be informed as appropriate e.g. Cambridgeshire and Peterborough Clinical Commissioning Group, GPs, Thorpe Hall Hospice, Cambridgeshire and Luton Local Intelligence Networks, Mount Vernon Cancer Network, local acute NHS Trusts This policy is to be implemented throughout all of the organisations operational and geographical areas by service managers, clinical managers and healthcare staff. By Sarah Woodley, Community Health Services Pharmacist Review date December 2014 or earlier if there is new national guidance, changes in treatment or legislation. Misuse of Drugs Act 1971 Misuse of Drugs Regulations 1997 and 2001 and subsequent amendments Care Quality Commission, essential standards of quality and safety Outcome 9 Management of Medicines National Patient Safety Agency (NPSA) alerts NHS Litigation Authority Risk Management Standards - - Standard 5 Criterion 10 Medicines Management and Medicinal Products: Prescription by Nurses Act 1992 Department of Health End of Life care Strategy 2008 Gold Standards Framework Cambridgeshire Community Services NHS Trust Medicines Management Policy and associated Medicine Management Standard Operating Procedures MMSOP for the Management of Controlled Drugs in Patients Homes Cambridgeshire Palliative Care Guidelines Group Fact sheets on Symptom Management http://www.arthurrankhouse.nhs.uk/default.asp?id=132 Mount Vernon Cancer Network Planned or Emergency Anticipatory Prescribing (Just in Case) Guidance November 2011 Cambridgeshire Community Services NHS Trust will ensure that this document is applied in a fair and reasonable manner that does not discriminate on such grounds as race, gender, disability, sexual orientation, age, religion or belief This document may have financial implications on the organisation including purchase of Just in Case bags, leaflets and prescription charts. Sarah Woodley: 01223 723053 Community Health Services Pharmacist sarah.woodley@ccs.nhs.uk anticipatory drugs, anticipatory prescribing, anticipatory medicine, just in case bag, just in case drugs, JIC, palliative care, end of life care Page 4 of 12

Contents Page 1. Introduction... 6 2. Objectives... 6 3. Duties... 6 4.1 Managers and Team leaders... 6 4.2 Prescriber... 7 4.3 Registered Nurse... 7 4. Training... 7 5. Guidance... 8 5.1. Setting up Anticipatory Prescribing... 8 5.2. Managing the Anticipatory Medicines in the Home... 9 5.3. Administration of Anticipatory Medicines... 10 5.4. Disposal... 10 6. Risk Management and Monitoring... 10 7. Specialist Advice and Information... 11 8. References... 11 Appendix 1 Flow Chart of Process... 12 Page 5 of 12

1. Introduction Many patients nearing the end of life wish to remain in their own home for as long as possible. However, they often experience distressing symptoms or become unable to swallow essential medicines such as analgesics or anti-emetics. It is essential that patients and the healthcare professionals looking after them have timely access to the medicines that can help if their condition changes suddenly at any time of the day or night, preventing unnecessary crises e.g. emergency admission to hospital, or prolonged / undue distress. Anticipatory prescribing ensures that there is no delay in responding to a symptom if it occurs. For patients in the community who are in the last few weeks of life, it is good practice for the prescriber (usually the GP) to prescribe a range of medicines which are kept in the home so that they are available for an attending healthcare professional to administer, if appropriate, following clinical assessment. Although each patient is an individual with individual needs, many acute events during the palliative period can be predicted and management measures put in place in advance. The decision to prescribe anticipatory medicines should be based on a risk / benefit assessment, and it is essential to discuss the need for anticipatory prescribing within the context of end of life care with both the patient and their carer as well as healthcare professionals involved. 2. Objectives This policy aims to: 3. Duties Improve access to palliative care medicines in the community by encouraging prescribers to anticipate common symptoms in the last few weeks of life e.g. pain, nausea and vomiting, respiratory secretions, agitation and anxiety, and prescribe sufficient quantities of the appropriate medicines which are dispensed and kept in the patient s home. Avoid distress in patients, carers and healthcare staff who do not have the correct medicine readily available, and help prevent unnecessary hospital admissions. Ensure prescribing complies with current legislation and takes place in a clear and safe manner that is understood by healthcare staff responsible for dispensing and administering the medication. Provide a safe framework for the use of anticipatory medicines in the home. 4.1 Managers and Team leaders Ensure that: The most recent version of the policy is available for use and any previous versions are removed from use. Relevant staff have read and understood the policy and have the necessary training and competencies. Medicines are handled in accordance with all Trust medicines management policies, and that the necessary equipment and supplies are available. Incidents and near misses are reported using the web-based Incident Reporting System (DATIX). A supply of Just in Case bags, leaflets and community prescription charts are available in all areas where they may be used. Page 6 of 12

4.2 Prescriber (The term prescriber includes doctor, independent prescriber, or supplementary prescriber working in accordance with individual patient clinical management plan.) Identify appropriate patients and prescribe anticipatory medicines in accordance with current legislation and the guidance in this policy. 4.3 Registered Nurse Identify appropriate patients and liaise with the prescriber regarding prescriptions and supply of anticipatory medicines in accordance with the guidance in this policy. Ensure adequate supplies of equipment (e.g. needles, syringes, sharps bin etc) are available in the home. Ensure adequate stocks of Just in Case bags, leaflets and prescription charts are available in all areas where they are used. Supplies are obtained from Arthur Rank House Hospice, Cambridge 01223 723110, Community Nursing Office, City Care Centre, Peterborough 01733 776207 and Community Nursing Team, Luton on 01582 707343. Ensure the patient and carers know whom to contact out of hours should any symptoms or problems occur. Ensure that appropriate records of receipt and administration of Schedule 2 Controlled Drugs (e.g. diamorphine and midazolam) are kept and that CDs are handled in accordance with the MMSOP for the Management of Controlled Drugs in Patients Homes. Check the anticipatory medicines regularly in accordance with this policy. Ensure that anticipatory medicines are disposed of in accordance with Trust policy. Ensure that all medicines are stored and handled in accordance with Trust policies and procedures. Ensure that they have received the necessary training and maintain and update their knowledge and skills in the relevant areas of practice. A record of CPD must be maintained as evidence. 4. Training This policy will be made available to all relevant healthcare staff. New healthcare staff to whom it applies are required to read the policy on induction. All healthcare staff must read the policy and seek further advice from their clinical manager or the Medicines Management Team if there are any aspects of the policy that they do not fully understand. Medicines should only be prescribed, dispensed and administered by staff that have the necessary knowledge and skills and are confident and competent to carry out this practice. Healthcare staff must identify their own training needs and inform their manager. The requirements for safe management of medicines may change due to changes in legislation or best practice guidance. It is therefore essential that all healthcare staff keep up to date with current practice. Staff should reflect on their medicines-related learning needs when discussing their Personal Development Plans with their manager. Page 7 of 12

5. Guidance See Appendix 1 Flow Chart of Process Anticipatory prescribing should be considered for all patients who are in the last few weeks of life. Some patients and / or carers may be unwilling to have anticipatory medicines; they may misinterpret anticipatory prescribing as provision for euthanasia or it may cause increased anxiety that death is near. However, good communication, reassurance and the explanatory leaflet should help to allay fears. Caution is needed where there is a history of drug misuse by the patient, family members, carers or visitors to the house, and a risk assessment should be undertaken. Consider prescribing smaller quantities of controlled drugs or using a lockable box for storage. 5.1. Setting up Anticipatory Prescribing Healthcare professionals should identify relevant patients ahead of need. The prescriber must prescribe the appropriate anticipatory medicines on an FP10 prescription to reflect the individual needs of the patient, taking into account current use of medicines for symptom control. The prescription should include one medicine for each of the following indications: pain, nausea and vomiting, respiratory secretions, agitation and anxiety. At least 5 ampoules of each medicine should be prescribed, but it is recommended that medicines are prescribed in a quantity that can be dispensed in the manufacturer s original pack where possible. The prescription is likely to include: Diamorphine or an alternative for pain Diluent (either sodium chloride 0.9% injection or water for injections) Haloperidol or levomepromazine for nausea and vomiting Midazolam for agitation / restlessness Glycopyrronium or hyoscine butylbromide (Buscopan ) for respiratory secretions Oral lorazepam tablets (Genus brand) for sublingual use by the patient for anxiety. N.B. This is an unlicensed method of administration. More information on the recommended medicines and doses used locally are included on the community prescription chart: Cambridgeshire and Peterborough chart (yellow) or Luton chart (blue). For further information on prescribing see 6 and 7. In addition to writing the FP10 prescription, the prescriber must write each of the subcutaneous anticipatory medicine on the As required / Anticipatory medicines section of the community prescription chart with clear instructions for use, including: Medicine name Dose Route Frequency Indication for use and maximum dose in 24 hours. Each entry must be signed and dated. Page 8 of 12

The syringe pump prescription should not normally be completed at this stage as it is not usually appropriate to anticipate an individual patient s requirements for continuous subcutaneous infusion of medicines in advance. The prescriber must explain the purpose of anticipatory prescribing / the Just In Case bag to patient and carer and explain that the medicines are for professional use only apart from the lorazepam tablets which can be self-administered by the patient or administered by the carer in accordance with the instructions on the label and the written leaflet supplied. The prescriber should ensure that the patient and / or carer know who to contact out of hours should any symptoms or problems occur. The prescriber should place a note on the patient s record to indicate that anticipatory medicines are held in the home, inform the Out of Hours Service and update the electronic palliative care register ( share my care ) where available. Supplies of Just in Case bags, leaflets and community prescription charts are available from Arthur Rank House Hospice, Cambridge 01223 723110, Community Nursing Office, City Care Centre, Peterborough 01733 776207, Community Nursing Team, Luton on 01582 707343. Leaflets are also available on the Trust intranet. 5.2. Managing the Anticipatory Medicines in the Home Once dispensed, the nurse should put the anticipatory medicines into a Just in Case bag if available, or clearly mark and store the medicines so that they can be easily identified in the patient s home. In addition, each patient receives: o A leaflet explaining the purpose of the anticipatory medicines / Just in Case bag o A leaflet explaining how and when the lorazepam tablets are used The nurse must: o Ensure that adequate supplies of equipment are available in the home for administration. o Record receipt of the anticipatory medicines in the patient s notes and complete the contact details for the patient / carer. o Record the strength and quantity of injectable Schedule 2 Controlled Drugs and midazolam (Schedule 3) received on the Controlled Drug Balance Record Form. The quantity of the Controlled Drug must be counted and recorded each time it is used or each time the bag is checked. (It is not necessary to record the balance of other injections or tablets). o Check the anticipatory medicines after one week and carry out a risk assessment for each patient and document how often the anticipatory medicines need to be checked. (However, they must be checked at least once every 4 weeks to ensure that nothing has been removed, used or expired without a record being made). o If the nurse cannot account for all of the controlled drugs, after enquiry with the family and health care team, the nurse must inform the team leader / manager who must inform the Accountable Officer and complete an incident form. The prescriber must: o Review the prescription at least once a month or after any changes to circumstances to ensure that the anticipatory medicines are appropriate both in terms of strength and type (NB - requirements may go up or down). o Update the community prescription chart if required. Page 9 of 12

5.3. Administration of Anticipatory Medicines When an anticipatory subcutaneous anticipatory medicine is administered from the bag: The administering healthcare professional must: o Record the medicine and dose given on the community prescription chart and update the balance record of any controlled drugs used. (It is not necessary to record administration of the oral lorazepam on the chart, but a record should be made in the notes stating the reason for use.) o Inform the patient s GP. o The nurse must reassess / review the frequency of checks in accordance with the patient s needs. The GP / prescriber must: o Review the patient s symptoms the patient may need a change in dose or medicine prescribed. o Prescribe replacement medicine if needed via FP10 prescription. o Consider a regular prescription for symptom control. o Update the community prescription chart for any new medicines or changes in dose / instructions. 5.4. Disposal When the episode of care finishes: A family member should return all medicines to a community pharmacy or dispensary for disposal as soon as possible, including Controlled Drugs. In exceptional circumstances, the registered nurse may return the drugs in accordance with the Trust Medicines Management policy and MMSOP for Management of Controlled Drugs in Patients Homes. All medicines are prescribed for the named patient only and must never be used for any other patient or returned to stock. 6. Risk Management and Monitoring The subcutaneous route is recommended for all injections. Many medicines administered via the subcutaneous route are not licensed for subcutaneous administration; therefore their use is off label. However, the effective use of medicines via the subcutaneous route is well documented and the prescriber should be conversant with such evidence and follow local policy on unlicensed medicines. The NPSA Safer Practice Notice 12 (May 2006) advises caution when prescribing parenteral diamorphine and morphine for patients who had not previously received doses of opiates. However, it is also important that clinicians have appropriate access to medicines of sufficient strengths and a good understanding of which medicine can be used to best effect. High dose morphine and diamorphine injections The NPSA Rapid Response Report (July 2008) aimed to reduce dosing errors with opioid medicines caused by a lack of understanding of how opioid medicines are dosed correctly, or inadequate checks on previous doses resulting in mismatching the needs of the patient with the dose prescribed. Every member of the healthcare team has a responsibility to check that the intended dose of an opioid medicine is safe for the individual patient. When opioid medicines are prescribed, dispensed or administered, the healthcare practitioner concerned should be familiar with the usual Page 10 of 12

starting dose, frequency of administration, standard dosing increments, symptoms of overdose and common side effects. Reducing dosing errors with opioid medicines Anticipatory prescribing in Cambridgeshire was audited in December 2009 and updated in 2011 in order to collect data relating to usage, cost and wastage of the anticipatory medicines and this identified that there were many benefits to patients, healthcare professionals and the organisation. This audit should be repeated when required. Healthcare professionals and /or carers may be asked to complete a questionnaire to determine the problems and benefits of the scheme. Any incidents or near misses concerning Anticipatory Prescribing, and remedial action taken must be reported through the web based incident reporting system and any areas of concern will be incorporated into the annual audit programme. 7. Specialist Advice and Information For further prescribing information refer to: o Cambridgeshire Palliative Care Guidelines Group Fact sheets at http://www.arthurrankhouse.nhs.uk/default.asp?id=132 o Thorpe Hall Hospice, Peterborough local guidelines o Mount Vernon Cancer Network Planned or Emergency Anticipatory Prescribing (Just in Case) Guidance November 2011 Specialist advice is available from your local hospice or specialist palliative care team: o Arthur Rank House Hospice, Cambridge (24 hour advice line) 01223 723110 o Thorpe Hall Hospice, Peterborough. 01733 330060 o Keech Hospice, Luton and South Bedfordshire (24 hour advice line) 08081 807788 o Luton Macmillan Specialist Palliative Care team (in working hours). 01582 560206 o St Johns Hospice, Bedfordshire.. 01767 642410 8. References Cambridgeshire Palliative Care Guidelines Group Fact sheets at http://www.arthurrankhouse.nhs.uk/default.asp?id=132 Gold Standards Framework; Examples of Good Practice Resource Guide Just in Case Boxes August 2006 Department of Health End of Life care Strategy 2008 Misuse of Drugs Regulations 2001 NICE guidance Improving Supportive and Palliative Care for Adults with Cancer Department of Health Guidance Securing Proper Access to Medicines in the Out of Hours Period National Patient Safety Agency NPSA National Patient Safety Agency Focus on Anticipatory Prescribing for end of life care. GPC guidance April 2012 Page 11 of 12

Appendix 1 Flow Chart of Process District Nurse / Clinical Nurse Specialist / GP identifies relevant patient ahead of need The prescriber prescribes appropriate anticipatory medicines on FP10 prescription The prescriber writes the anticipatory medicines (except Lorazepam) on the community prescription chart in the as required / anticipatory medicine section The GP, District Nurse or Clinical Nurse Specialist explains the purpose of the anticipatory medicines / JIC bag to patient and carer and that all items are for professional use only (except lorazepam which can be used in accordance with the label and written leaflet supplied) and ensures that the patient and / or carer knows who to contact out of hours should any symptoms or problems occur The prescriber puts a note on the patient s to record that anticipatory medicines are held in the home, informs the OOH Service and updates the electronic palliative care register ( share my care ) where available The nurse puts the dispensed anticipatory medicines into a Just in Case bag if available, or clearly marks and stores the medicines so that they can be easily identified in the patient s home. The nurse ensures adequate supplies of equipment are available in the home for administration The nurse records receipt of the anticipatory medicines in the patient s nursing notes. The strength and quantity of Schedule 2 Controlled Drugs and midazolam (Schedule 3) received is recorded on the CD balance record form. The nurse checks the anticipatory medicines / Just in Case bag after one week and carries out a risk assessment for individual patient to decide how often the anticipatory medicines need to be checked, this must be documented. The anticipatory medicines must be checked and recorded at least once every 4 weeks. The prescriber reviews the prescription / medicines at least once a month or after any changes to circumstances When items are used: The administering nurse / doctor records the medicine and dose given on the community prescription chart and informs the patients GP. The prescriber reviews the patient s symptoms, prescribes replacement medicines if needed via FP10 prescription, considers a regular prescription for symptom control and updates the prescription chart for any new medicines or changes in dose / instructions. When episode of care finishes: A family member returns all medicines to a pharmacy for disposal as soon as possible including Controlled Drugs. (In exceptional circumstances, the registered nurse may return the drugs in accordance with the Trusts Medicines Management policy). Returned medication must never be reused for any other patient or returned to stock. Page 12 of 12