Policy for Pre-Emptive Prescribing and Supply of Palliative Care Medications for Adults

Lincolnshire Community Health Services NHS Trust United Lincolnshire Hospitals NHS Trust Lincolnshire Partnership Foundation NHS Trust St Barnabas Lincolnshire Hospice Marie Curie Cancer Care Working in partnership Policy for Pre-Emptive Prescribing and Supply of Palliative Care Medications for Adults Reference No: Version: 2.1 Ratified by: P_CS_18 LCHS Trust Board Date ratified: 8 th March 2016 Name of originator/author: Name of responsible committee/individual: Date Approved by committee/individual: Petra Clarke, Jenny Hinchliffe & Access to Palliative Care Medicines Group Drug and Therapeutics Committee 10 th February 2016 Date issued: March 2018 Review date: August 2018 Target audience: Distributed via: All Staff Website

Policy for Pre-emptive Prescribing and Supply of Palliative Care Medications for Adults Version Control Sheet Version Section/Para/A ppendix Version/Description of Amendments Date Author/Amended by 1 New April 2013 Petra Clarke 1.1 4 month extension agreed and changes to footers and logo s 1.2 1.3 2 Throughout Section 9 Extension to review date Extension agreed awaiting new guidelines Update references Update Links Revised CD1 form Update the best practice framework. Add changes re: informal carer s administration. Storage in patients homes. 2.1 Extension agreed to allow amendments with external organisations 3 4 5 6 7 8 9 10 11 12 13 14 15 June 2015 August 2015 November 2015 February 2016 March 2018 C Kern N Jackson Corporate Assurance Manager Lorna Adlington Lorna Adlington Page 2 of 31

Copyright 2018 Lincolnshire Community Health Services NHS Trust, All Rights Reserved. Not to be reproduced in whole or in part without the permission of the copyright owner. Lincolnshire Community Health Services NHS Trust Policy for Pre-emptive Prescribing and Supply of Palliative Care Mediations for Adults i. Version control sheet ii. Policy statement 1. Introduction 6 Contents Page Number 2. Policy Statement 6 3. Equality Impact Assessment 7 4. The Scheme 7 5. Known risks 7 6. Pre-emptive prescribing medications 8 7. The Process 8 7.1 Suitable patients 8 7.2 Patient Consent 9 7.3 Communication with other teams 9 7.4 Prescription requirements 9 8. Collection & Delivery Arrangements 10 9. Storage of the Medications 10 10. Authorisation & Administration of Medication 11 11. Using the Palliative Care Medication 11 12. Checking drug stocks 11 13. Discrepancies 12 14. Information Sheets 12 15. Medication No Longer Required 12 16. Process for accessing palliative care medication out of hours 12 Page 3 of 31

17. Audit and monitoring arrangements 13 18. Responsibility 14 19. Review 14 20. Evidence Base 14 Appendices Appendix 1 Process for Accessing Palliative Care Medications Out of Hours - Flowchart 15 Appendix 2 List of Palliative Care Drugs stocked (including CDs) by the Out of Hours Service of Unscheduled Care 16 Appendix 3 Pharmacies stocking palliative care medications 17 Appendix 4 CD1 (direction to administer treatment), CD2 &CD3 forms 18 Appendix 5 Patient Information Sheet 23 Appendix 6 Out-of-Hours Handover Form 24 Appendix 7 FP10 Prescription completed example 25 Appendix 8 Equality Impact Assessment 26 Appendix 9 NHSLA Monitoring Template 31 Page 4 of 31

Policy for Pre-emptive Prescribing and Supply of Palliative Care Mediations for Adults Policy Statement Background Statement Responsibilities There are a number of end of life tools in use in practice within Lincolnshire to support the improvement of, and best practice in, end of life care. These include the Gold Standards Framework (GSF), Advance Care Planning (ACP) and the Five priorities for day of the dying person. These frameworks help to develop and implement a standard of quality care, including pre-emptive prescribing for distressing symptoms. The Trust supports pre-emptive prescribing and rapid access to medicines commonly prescribed in palliative care by ensuring a small stock of palliative care medications has been prescribed, dispensed and placed in the patient s home where appropriate. It also supports effective team working between doctors, nurses and pharmacists, both in and out of normal working hours. This policy defines the process for accessing palliative care medication and aims to improve prompt access to symptom control for patients receiving palliative care. Compliance with this policy will be the responsibility of all registered practitioners. Training Training will be provided by specialist palliative care teams/providers to support implementation. Dissemination Resource implication Consultation Via the intranet, staff briefings and through clinical team leads. Prompt access to symptom control for patients who are dying will contribute to the reduction of emergency admissions for these patients and support patients who choose to die at home. LCHS Business Units and Community Nursing Team Leads, Out of Hours Teams, Macmillan Nurse Specialists, General Practitioners, Marie Curie Cancer Care, St Barnabas Hospice, ULHT Professional Standards Board. Page 5 of 31

Policy for Pre-emptive Prescribing and Supply of Palliative Care Mediations for Adults 1 Introduction 1.1 There are a number of end of life tools in use in practice within Lincolnshire to support the improvement of, and best practice in, end of life care. These include the Gold Standards Framework (GSF), Advance Care Planning (ACP) and the Five priorities for the day of the dying person. These frameworks help to develop and implement a standard of quality care, including pre-emptive prescribing for distressing symptoms. 1.2 Involving patients and their carers in decisions about their end of life care and improving access to high quality personalised care closer to home at end of life is a key focus within Lincolnshire. Although between 60 and 67% of people in England have stated that they would prefer to die at home (Cicely Saunders International 2011), approximately 42% of deaths occurred at home/care home and 50% in acute hospitals in Lincolnshire in 2011 (NHS Lincolnshire). Uncontrolled symptoms and the absence of pre-emptive prescribing are contributory factors which influence whether a patient is able to die in their place of choice and may result in hospital admission. 1.3 The Department of Health document published in December 2004 Delivering the Out-of-Hours Review: Securing proper access to medicines in the out-of-hours period recommends prompt and easy access to palliative care medicines in the out-of-hours period (action points 8 and 9). http://webarchive.nationalarchives.gov.uk/+/www.dh.gov.uk/en/publicationsandstati stics/publications/publicationspolicyandguidance/dh_4134236 1.4 Often towards the end of life patients are unable to take oral medication therefore parenteral administration is required via PRN injection or a syringe driver to control symptoms. This medication needs to be available immediately to the health professional making the assessment of a patient s condition and subsequent deterioration. Therefore it is recommended that the patient s GP or a non-medical prescriber (NMP) prescribes medication in advance of deterioration and that these drugs are available in the patient s home. 2 Policy Statement 2.1 Lincolnshire Community Health Services NHS Trust, United Lincolnshire Hospitals NHS Trust, Marie Curie Cancer Care, St Barnabas Hospice Trust and the Clinical Commissioning Groups support pre-emptive prescribing and rapid access to medicines commonly prescribed in palliative care by ensuring a small stock of palliative care medications has been prescribed, dispensed and is available in the patient s home. The medicines are targeted at patients reaching the terminal phase of their illness. They also support effective team working between all health professionals, both in and out of normal working hours. The aim is to provide prompt access to symptom control for patients receiving palliative care, contribute to the reduction of emergency admissions for these patients and support patients who choose to die at home. Page 6 of 31

3 Equality Impact Assessment 3.1 The organisations aim to design and implement services, policies and measures that meet the diverse needs of their services, population and workforce, ensuring that none are placed at a disadvantage over others. This policy will not adversely affect any group on the basis of race, ethnic origins, nationality, gender, culture, religion, belief, sexual orientation, age or disability. See appendix 8 for full assessment. 4 The Scheme 4.1 A community healthcare practitioner, in liaison with the general practitioner, will identify an adult patient requiring palliative care support in their home. If it is anticipated that the patient s medical condition may deteriorate into the terminal phase of illness and with the patient and carer s agreement, the prescriber can prescribe a stock of pre-emptive palliative care medications which will be available in the home for immediate symptom management. 4.2 The patient/carer will take the prescription or an electronic transfer of the prescription will be sent to a community pharmacy to receive the dispensed medications. If the patient s local pharmacy does not stock the required medications, a list of pharmacies that stock palliative medications is available as an appendix (see Appendix 3) as well as on the LCHS Medicines Management webpage. 4.3 The nurse will record a list of the medications in the patient s documentation and put the medications in the Just in Case box to be kept at the patient s home for rapid administration of medicines commonly prescribed for breakthrough symptom control. If a Just in Case box is unavailable, the patient/carer should be advised to store the medication in a safe but accessible place (Reference should be made to the Controlled Drugs Policy). Equipment to administer the medication (e.g. needles and syringes) and for the safe disposal of sharps should be stored with the medication. 4.4 All medicines will need to be authorised (doses, indication, directions, signed and dated) by the prescriber on a CD1 form (the direction to administer treatment for symptom management and controlled drugs form currently used see Appendix 4 for completed example) in order to enable administration of the prescribed medication. 5 Known Risks There are few known risks: 5.1 As with all drugs open to abuse, medicines supplies in patients houses may be open to abuse. 5.2 Patients and/or carers may misinterpret pre-emptive prescribing as provision for euthanasia or cause increased anxiety that death is near, however good Page 7 of 31

communication and use of the patient information leaflet (Appendix 5) should allay fears. 6 Pre-emptive prescribing medications 6.1 The aim is to provide enough medication to potentially last for a 24-48 hour period e.g. if out of hours GP or non-medical prescriber starts subcutaneous medication on a Saturday night there is enough to last until Monday morning when most GP surgeries and local pharmacies are open again. Doses must be individualised. Below is a suggestion of dispensing quantities that may be prescribed for someone who is not already taking any of these medications. If patients are already on this medication orally or parenterally, this would need to be taken into account when deciding the strength and quantity to prescribe. Table 1 Example Medicine Strength Quantity * Diamorphine hydrochloride 5mg 5 x 5mg ampoules Metoclopramide 10mg/2ml 10 x 10mg ampoules Midazolam 5mg/ml 10 x 10mg ampoules Hyoscine butylbromide 20mg/ml 10 x 20mg ampoules Water for injection 10 x 10ml ampoules * If patient is already on this medication then the quantity and strength needs to be individualised to ensure correct dose is available for parenteral medication. 7 The Process 7.1 Suitable patients 7.1.1 A patient is identified as appropriate for a pre-emptive medication by a GP or community nurse. Usually the medication is introduced in the last few weeks of life (equating to yellow status on the GSF traffic light system: see Prognostic Indicators Guidance: http://www.goldstandardsframework.org.uk/cdcontent/uploads/files/general%20files/prognostic%20indicator%20guidance%2 0October%202011.pdf 7.1.2 Some patients may be unwell but others may be relatively well at the time of initiation of the pre-emptive medication their introduction should be reviewed weekly. 7.1.3 A health care professional must have completed a risk assessment including assessing whether there are drug misusers who have access to the house. Consideration of which palliative care pre-emptive medications it is appropriate to prescribe to patients whose homes are known to be accessed by drug misusers will need discussion within the General Practice multi-disciplinary team. Page 8 of 31

7.2 Patient consent 7.2.1 The provision of a pre-emptive medication must be discussed with the patient and where appropriate the family and carers, in order to explain its function and acceptability; consideration must be given to whether communication needs to be aided by the use of other support resources e.g. interpretation services. 7.2.2 Where the patient has the capacity to consent, consent will be gained but it is recognised that a number of patients will have lost capacity to agree to the preemptive supply of palliative care medications. 7.2.3 In cases where an adult does not have the capacity to consent then consideration needs to be given as to whether this is in the individual s best interests. This would include discussion with relatives, carers or friends. For further information, see Mental Capacity Act 2005 (LCHS at: http://www.lincolnshirecommunityhealthservices.nhs.uk/policies-and-guidelines Please refer to the Lincolnshire Community Health Services Policy for Consent to Examination or Treatment available at http://www.lincolnshirecommunityhealthservices.nhs.uk/policies-and-guidelines or your local trust policy. 7.3 Communication with other teams 7.3.1 The patient must have been referred to the community nursing team for nursing assessment and the introduction of nursing notes into the home. Referral to the Palliative Care Co-ordination Centre on 0845 0550708 should be made as appropriate. 7.3.2 Communication with the Out-of-Hours service and Marie Curie Rapid Response must occur using the handover form (appendix 6) stating that pre-emptive medications are in the patient s house. This must also be documented in the Systmone Palliative Care Template where in use. The handover form can also be used to communicate patient preferences for place of care and any Advanced Decisions to Refuse Treatment or resuscitation decisions (see SOP for Access To Out of Hours Care For Adults With Palliative and End of Life Care Needs available at: http://www.lincolnshirecommunityhealthservices.nhs.uk/policiesand-guidelines 7.4 Prescription requirements 7.4.1 A normal FP10 prescription is generated for the medicines contained in the Palliative Care Pack and signed by the GP or NMP caring for the patient. The correct quantities must be specified and prescriptions for parenteral morphine and midazolam are subject to controlled drugs regulations. See appendix 7 for completed example. 7.4.2 It may be possible to incorporate this into a computer template taking care to identify any patient specific issues e.g. allergies and/or interactions. Page 9 of 31

7.4.3 The prescription must clearly state In anticipation for all medications (Appendix 7). 7.4.4 If prescribing a dose range ensure that the direction on the prescription and the Gold CD1 Form always reflect the instructions on the medicines box. For example, the prescription should be written Diamorphine 10mg ampoules: to be given as directed in association with a prescribed dose range written on the Gold Form (CD1) (see Standard Operating Procedure for handling Controlled Drugs within LCHS Community Nursing Services) 7.4.5 A prescription for the Palliative Care Pack for Diamorphine should typically contain the following instructions: E.g. Diamorphine hydrochloride 5mg, 5 (five) ampoules. Dose 2.5mg subcutaneously for pain. The dose, strength and number of ampoules need to be individualised. 7.4.5 A prescription for the Palliative Care Pack for midazolam should typically contain the following instructions: E.g. Midazolam 10mg/2ml, 5 (five) ampoules. Dose 5mg subcutaneously for agitation. The dose, strength and number of ampoules need to be individualised. 7.4.6 As a guide for dosages please see latest edition of Palliative Care Formulary, the Palliative Adult Network Guidelines (PANG) (available at http://book.pallcare.info/. This must include sufficient quantities for breakthrough doses to be dispensed. 8 Collection & Delivery Arrangements 8.1 The GP or NMP is responsible for writing the prescription. If not a dispensing GP Practice, the patient/carer is responsible for taking the prescription to a community pharmacy (see appendix 3 for location of pharmacies agreeing to stock and supply the listed medications). 8.2 The medications should either be collected by the patient or their nominated carer, or they could be delivered to the patient s home using the pharmacy s delivery service where the pharmacy is able to offer this service. 8.3 A prescription for controlled drugs is valid for 28 days. The patient/carer should be advised to arrange for the medications to be dispensed without delay. 9 Storage of the Medications 9.1 The patient or carer is responsible for storing the medications in the house. N.B. medications need to be stored at the correct temperature and any medications requiring refrigeration should be stored accordingly. 9.2 Controlled drugs for all patients cared for within their own homes should be stored in a clear plastic container for security and monitoring. Page 10 of 31

9.3 The nurse should advise the patient/carer that the medication should be stored out of reach and sight of children if there are children present in the house, and should be accessible to the healthcare professionals caring for the patient. 9.4 The nurse ensures that the CD1, CD2 and CD3 forms (appendix 4) are in the notes in the house. 9.5 The nurse indicates in the community nursing notes where the medication is located. 10 Authorisation & Administration of Medication 10.1 Drugs cannot be administered by the community teams unless the medicines are authorised (prescribed doses, indication, directions, signed and dated) by a prescriber on a CD1 form. 10.2 Many clinical scenarios in end of life care can be anticipated such as a patient being unable to take oral medication. Where appropriate, medicines should be prescribed in advance and stock arranged so that the drugs are available should they be required, for example, for subcutaneous breakthrough doses for pain management. 10.3 The name of the medicine, dose, route of administration, batch number and expiry date should be checked prior to administration in the usual manner. 11 Using the Pre-emptive Medication 11.1 Only a healthcare professional qualified to administer medication and accountable to the organisation for care of the patient may administer a medicine from the preemptive supply. 11.2 Local policy changes now support informal carers to administer as required medications subcutaneously following a strict protocol. This policy can be found http://www.lincolnshirecommunityhealthservices.nhs.uk/policies-and-guidelines 11.3 If some of the medicines are administered, details should be recorded in the patient s community nursing notes in the usual way. 11.4 If drugs are administered by the out-of-hours team or Marie Curie Rapid Response nurse, the doctor or nurse is responsible for informing the GP practice and nursing team the next working day that the medication has been administered and the rationale for use. 12 Checking drug stocks 12.1 It is the responsibility of the attending practitioner to check the drugs and record stock on the CD2 form. Weekly stock checks must be performed until commenced. Refer to the SOP for Handling Controlled Drugs within LCHS Community Nursing Services for further information http://www.lincolnshirecommunityhealthservices.nhs.uk/policies-and-guidelines Page 11 of 31

13 Discrepancies 13.1 If a GP or nurse/practitioner finds that the stock of medications do not match the details on the CD1 form / CD3 (stock management sheet) and/or if the form has not been completed, the practitioner should attempt to identify who accessed the medication by checking the nursing notes or checking with the practice. 13.2 If the healthcare professional finds any discrepancies not resolved by the above measures then the guidance for reporting discrepancies in the SOP for Handling Controlled Drugs within LCHS Community Nursing Services must be followed immediately upon discovery. 14 Information Sheets 14.1 Medications are provided with the medicinal product s patient information leaflets and the healthcare professional administering the medications must ensure the patient has access to the relevant leaflet, as well as the Pre-emptive Medication Patient Information Sheet (Appendix 5). 15 Medication No Longer Required 15.1 When the patient has died it is the responsibility of the community nurse to collect the syringe driver and box, having removed any unused medications and recorded these clearly on the CD1 and CD3 form. 15.2 It is the responsibility of the relatives or carer to return any unused medications to a pharmacy and it is appropriate for the nurse to remind the carer of this. 15.3 The risk of contamination of the syringe driver and box is low and cleaning should be performed in accordance with the syringe driver policy available at: http://www.lincolnshirecommunityhealthservices.nhs.uk/policies-and-guidelines 16 Process for accessing palliative care medication out of hours Options for accessing medication (See Appendix 1 for flowchart) 16.1 The process for accessing palliative care medication out of hours can be found in appendix 1. 16.2 If a nurse working for LCHS or the Marie Curie Rapid Response Service has an FP10 for a CD that has been written by a prescriber in the community but which could not be filled by a local pharmacy, the OOH doctor / NMP should transcribe the prescription on to an FP10P-REC and supply the CD to the patient via the nurse from the stock in the OOH base. The FP10 should then be cancelled and attached to the newly written / printed FP10P-REC. These and any other CD prescriptions should be retained in a secure place for two years. 16.3 If a nurse working for LCHS, or the Marie Curie Rapid Response Service does not have a FP10 but requires palliative care medication, an FP10P-REC should be written; the prescription should then be assembled and labelled by a doctor / NMP and one other healthcare professional. Page 12 of 31

16.4 The CD record book should be completed as per the service specific and organisations CD SOP. 16.5 The issuing of the CD from the OOH stock should be second-checked by another healthcare professional. In exceptional circumstances, if there is only one doctor / NMP on duty and no other healthcare professional available then the doctor / NMP should request a check from another competent staff member e.g. HCSW as per the SOP for Handling Controlled Drugs within LCHS Community Nursing Services. If applicable the doctor / NMP should document that there has been no second check from another healthcare professional. 16.6 If there are no community pharmacies available to dispense the prescription and there is not an adequate supply of the necessary medication at the OOH site, then the on-call Community Pharmacist should be contacted, an up to date list is held at the OOH Service. 16.7 The final option is to call the local Acute Trust pharmacist who should be contacted via their hospital switchboard. This service is available out-of-hours every day of the year: but this is the final option for sourcing a supply of palliative care medication including CDs, if all other legally permissible community routes are not available. The on-call pharmacist will verify the identity of the prescriber by calling the OOH centre before agreeing to dispense the prescription. The prescription must be transferred and drugs collected from the hospital pharmacy by a member of OOH staff and not a carer / patient. Please note: Healthcare professionals should always be mindful of, and work within the scope of, their professional code of conduct when handling CDs The responsibility for locating a pharmacy or otherwise making arrangements for supply of medicine does not lie with the patient or their representative but rests with the out-of-hours provider (Securing Proper Access to Medicines in the Out of Hours period, DH guidance) 17 Audit and monitoring arrangements 17.1 Compliance with this policy will be subject to audit and will be checked as part of the annual CD audit. 17.2 All FP10P-RECs for CDs should be completed fully and legibly and should be securely retained for a period of two years to support the CD account. 17.3 All such FP10P-RECs will be subject to scrutiny by the organisation to ensure that the policy has been followed and that CDs have been accessed appropriately. 17.4 The CDRB and related documents will be inspected regularly as part of on going monitoring requirements relating to CDs. Page 13 of 31

17.5 Staff who wish to raise any questions about accessing CDs for palliative care out-of-hours should do so with their line manager or the Accountable Officer for Controlled Drugs. 18 Responsibility 18.1 Prescribers working for the out-of-hours service of Unscheduled Care will follow this policy. 18.2 The OOH site Team Leader is responsible for ensuring compliance with this policy and should report any failure to comply with this policy to their service manager. 18.3 The ultimate responsibility for the management of CDs lies with the relevant organisation s Accountable Officer. 19 Review Following implementation, this policy shall be subject to review, in accordance with any change in the law or in working practices. It may also be reviewed following audit or error reporting which has identified any risk with the existing procedure. Staff operating under this policy are encouraged to consider and comment on content if potential improvements are identified. 19 Evidence Base Department of Health (2008) End of Life Care Strategy: Promoting High Quality Care for All Adults at the End of Life. Department of Health (2004) Delivering the Out-of-Hours Review: Securing proper access to medicines in the out-of-hours period a practical guide for PCTs and organised providers. Available at: http://www.dh.gov.uk/en/publicationsandstatistics/publications/publicationspolicy AndGuidance/DH_4134235 Gold Standards Framework (2006) Examples of Good Practice Resource Guide Just in Case Boxes. Available at: http://www.goldstandardsframework.org.uk/resources/gold%20standards%20fr amework/test%20content/examplesofgoodpracticeresourceguidejustincase Boxes.pdf Mental Capacity Act (2005) HMSO: London. Gold Standard Framework Prognostic Indicator Guidance (2011). Available at: http://www.goldstandardsframework.org.uk/resources/gold%20standards%20fr amework/general/prognostic%20indicator%20guidance%20october%202011.p df LCHS (2015) Standard Operating Procedure for Handling Controlled Drugs within Lincolnshire Community Health Services. NHS Lincolnshire (2016) Policy relating to the prescribing, supply, storage and disposal of controlled drugs in primary care. LCHS (2014) Standard Operating Procedure for Access To Out of Hours Care For Adults with Palliative and End of Life Care Needs. Page 14 of 31

LCHS (2014) Planning for Future Care Guidance: Advance Care Planning, Advance Decisions to Refuse Treatment & DNACPR. LCHS (2014) McKinley T34 Syringe Driver Policy for Adults in Palliative Care. Page 15 of 31

Patient requires a supply of palliative care medication Out of Hours The patient has a valid FP10 which needs to be dispensed No Patient or nurse contacts the OOH Service Yes OOH Service makes an assessment of the medicines required and quantities to be supplied until further routine supply can be made Local pharmacy can dispense the FP10 Yes local pharmacy dispenses NO - some or all medicines not available Refer to Community Pharmacy map for stockists of drugs OOH Service to refer to Community Pharmacy map for stockists of drugs YES - OOH Service confirms that a community pharmacy has sufficient stock to dispense and ensures that an FP10NC is written correctly to enable pharmacy to supply the medication YES NO Prescription to be dispensed from OOH stock of pre-emptive palliative drugs Confirm who is going to collect the medication. Remember that it is the OOH service responsibility to ensure that the medicines are accessible by the patient/carer so if a carer or district nurse is unable to collect the medication the OOH service must make arrangements for this to happen OOH Service writes an FP10P- REC, dispenses and labels accordingly. To be second checked if possible and ensures CD1 form is updated NO insufficient stock available at OOH OOH Service to contact: 1. Community Pharmacy on call service If there is no alternative then: 2. Acute Trust switchboard for on call pharmacist to supply the required URGENT END of LIFE medication. OOH Service must write an FP10NC and organise delivery of the medication to the patient s home. Page 16 of 31

Appendix 2: List of Palliative Care drugs stocked (including CDs) by the Out-of-Hours Service of Unscheduled Care Controlled drug: Diamorphine 5mg injection Diamorphine 30mg injection Midazolam 5mg/ml 2ml inj Quantity stocked 15-20 ampoules 15-20 ampoules 10-20 ampoules Palliative Care drug Dexamethasone injection 4mg/ml (1 ml ampoules) Metoclopramide injection 10mg/2ml Cyclizine injection 50mg/ml Haloperidol injection 5mg/ml Levomepromazine injection 25mg/ml Hyoscine butylbromide injection 20mg/ml Water for Injection 10mls Quantity stocked 10 ampoules 10 ampoules 10 ampoules 10 ampoules 10 ampoules 10 ampoules 10-20 ampoules Page 17 of 31

Appendix 3 Community Pharmacies stocking palliative care medications to be confirmed Page 18 of 31

Appendix Four INITIATED BY: GP LCHS ULHT LPFT ST. Barnabas Hospice Community Prescriber to review within 72 hours. Lincolnshire Community Health Services NHS Trust United Lincolnshire Hospitals NHS Trust Lincolnshire Partnership Foundation NHS Trust St Barnabas Lincolnshire Hospice Marie Curie Cancer Care Working in partnership CD1 Direction to administer treatment for symptom Management and Controlled Drugs Section Page Number: Patient s Name:.. NHS No:.. DOB: Drug Allergies: TRANSDERMAL OPIOIDS Date Drug Name Dose Frequency Signature in full Print name below DRUGS TO BE GIVEN VIA A SYRINGE DRIVER To be given subcutaneously over 24 hours (including pre-emptive) Please see guidance on reverse of form for administration within a dose range Date Prescribed Date Commenced Drug Dose Range Indications for Use Signature in full Print name below OTHER MEDICATION (including pre-emptive) and PRN DATE Indications for use Pain Drug Dose Range Route Frequency Signature in full Print name below Pain Nausea/ Vomiting Agitation Respiratory secretions Breathlessness Other NB: The pre-emptive prescriptions should be reviewed at least weekly and ensure PRN doses are adjusted as required by any change in syringe driver doses. For clarity, all old prescriptions should be scored through and dated with the date discontinued.

PRESCRIBING GUIDELINES The information within these guidelines is referenced to and should be used in conjunction with Palliative Care Formulary 4, Palliative Adult Network Guidelines 2011 and the current British National Formulary. Be aware of drug accumulation in renal failure and seek guidance to alternative medication. Prescribing responsibility remains with the prescriber. Maximum doses may be extended and some maximum doses only to be used following discussion with a Specialist Palliative Care Clinician. Please note that only Diamorphine, Oxycodone and Levomepromazine are licensed for subcutaneous use. It is accepted practice in palliative care to administer other appropriate drugs via the subcutaneous route. It is recommended that no more than 3 drugs are combined in one syringe. Drug compatibility information can be found in the PCF4 and on the following websites: www.palliativedrugs.com and www.pallcare.info Guidance for administration within a prescribed dose range Adjustments should be made in the context of your clinical assessment. Add the previous 24 hours infusion dose (A) to the total breakthrough doses in the last 24 hours (B) to calculate the next 24 hour infusion dose (C) A+B=C A = Previous 24 hour infusion dose B = Total of all breakthrough doses in the last 24 hours = C = Next 24 hour infusion dose (if this exceeds the dose range prescribed, seek advice from an appropriate prescriber) Drugs for subcutaneous use in syringe driver over 24 hours The following are suggested starting doses and usual maximum doses. The dose used should be adjusted according to individual patients, previous oral medication and symptoms. ANALGESIC Diamorphine Calculate previous 24 hours total oral morphine dose and divide by 3. If opiate naïve starting dose 5mg. Subcutaneous STAT doses of drugs Stat doses vary according to the dose of medication in the syringe driver and individual patient. 1/6 th of syringe driver dose given over 24 hours. If opiate naïve: 2.5mg 2 4 hourly. Morphine injection Calculate previous 24 hours total oral morphine dose and divide by 2. Oxycodone Oxynorm Injection Calculate total oral oxycodone dose in last 24 hours and divide by 2. NB Not compatible with Cyclizine 1/6 th of syringe driver dose given over 24 hours. 2 4 hourly. 1/6 th of syringe driver dose given over 24 hours. 2 4 hourly. ANTI-EMETIC Cyclizine Needs to be well diluted to prevent crystallisation and/or skin irritation and should never be diluted in normal saline 0.9%. Haloperidol STARTING DOSE 100 150mg 1.5mg MAXIMUM DOSE IN 24 HOURS (Including PRN) 150mg 5mg 50mg 8 hourly Choose Haloperidol or Levomepromazine for stat dose 500 micrograms 3 mg 8 hourly Levomepromazine Also sedative at any dose 6.25mg 25mg 50mg 6.25mg 12.5mg 4-6 hourly Metoclopramide 30mg 60mg 100mg 10mg 30mg 8 hourly (Large volume more suited for I.M. route) ANTI-SECRETORY Hyoscine Butylbromide 20mg 60mg 120mg 10mg 20mg 8 hourly Glycopyrronium 600 micrograms 1.2mg ANTI-SPASMODIC Hyoscine Butylbromide 60mg 120mg 20mg 8 hourly CONFUSION / RESTLESSNESS Midazolam 5mg 30mg 60mg (100mg*) 200 micrograms 400 micrograms 6-8 hourly 2.5mg 10mg 4 hourly Levomepromazine (Dilution with water for injection is normal practice. However, if the site reacts, normal saline 0.9% is suggested.) 6.25mg 75mg 150mg (250mg*) *Under specialist advice only 6.25mg 12.5mg 4-6 hourly If symptoms do not respond please seek early advice; contact a Macmillan Nurse or St Barnabas Hospice on: 01522 511566 OR Thorpe Hall Hospice on: 01733 225900

CD2 DRUG STOCK Patients Name: DOB:. NHS No Drug Name. Dose:. Section page no Date Time Dose Used Dose Wasted Stock Balance Signature

CD3 RECORD OF DRUG ADMINISTRATION BY HEALTH PROFESSIONAL Patient s Name:. NHS Number Section page number Date of Birth:. Date Records in this section Commenced: Date Records in this section completed. Syringe driver 1 Asset number Model Date Set up. Date Discontinued Syringe driver 2 Asset number Model.. Date Set up. Date Discontinued Please record all medication administered by any route. Include all regular and PRN doses in sequential order. DATE TIME Driver no. and model MEDICATION Dose Given Route Rate setting Duration Time started Time discontinued expiry date Batch number GIVEN BY: (Signature in full) PRINT NAME BELOW Page 22 of 31

Appendix 5 Palliative Care Medications Patient and Carer Information When you become more unwell there may be a stage where you are unable to swallow medicines by mouth. If you have problems e.g. with pain or sickness, they will need to be controlled with injections via a small needle just underneath the skin. It is important that this is done quickly so that you remain comfortable. We are therefore giving you a prescription for medicines in advance of this situation arising. The medicines will vary from patient to patient. You may not need them, but just in case, the common ones are: Diamorphine - for pain and breathlessness Metoclopramide - for sickness Midazolam - for restlessness Hyoscine - for secretions in the throat What you need to do: 1) Take the prescription to the pharmacy as soon as convenient. 2) Once dispensed take the medications home and contact your nurse. The nurse will come and check them, list them on a drug stock sheet and ask you to store them in a place accessible to the healthcare professionals involved in your care. The medicines have been prescribed for you and must not be given to anyone else. If you have worries that someone who comes into your house misuses drugs please inform either the nurse or doctor so alternative arrangements can be made for your medicines. The medicines need to be kept in a safe place. They do not need to be kept in the fridge. They must be kept out of sight and reach of children. 3) Please tell any doctor or nurse advising or treating you that there are Palliative Care Medicines available in the house. 4) It is very important that medicine that is no longer needed is returned by family/carers to the pharmacy where it was obtained. Unfortunately health professional are unable to return medication to the pharmacy. This information can also be made available upon request in Braille, audio cassette, large print or in other languages.

Appendix 6 Out-of-Hours Handover Form Palliative Care Out of Hours and Rapid Response Service Handover Form Name DOB NHS No Diagnosis Date of diagnosis Other Conditions Address Family / carers contact details Postcode Are they aware of diagnosis and prognosis? Tel No. Personnel involved Key Worker GP... Case Manager.. NIT.. Palliative Care Coordination Centre Y/N.. Macmillan/CNS. St Barnabas H@H Team... Marie Curie Night Care Y/N ACP Y/N ADRT Y/N. Details... DNACPR with patient Y/N.. LCP Y/N Palliative Care Template Completed Y/N Responsive Need Tool Level. Treatment Current Medication and Allergies Pre emptive Medication Y/N Details: Prescription and Administration Chart Available Y/N Priorities (Problems and concerns physical, psychological, social, spiritual any other relevant information) Preferred place of care (dated) Preferred place of death (dated) Place of death Date of Death Page 24 Completed of 31 by Designation... Date..

Appendix 7 FP10 prescription completed EXAMPLE Age D.O.B. DOB Name (including forename) and address A. Patient Address Dispenser s endorsement Pack & quantity Number of days treatment N.B. Ensure dose is stated Levomepromazine 25mg/ml 3 x 1ml ampoules. DOSE mg as directed in anticipation of nausea or agitation NP Midazolam 5mg/ml. 6 (six) x 2ml ampoules. DOSE mg as directed in anticipation of agitation Hyoscine butylbromide 20mg/ml. 4 x 1ml ampoule. DOSE mg as directed in anticipation of bronchial secretions Pricing Office Diamorphine hydrochloride 5mg ampoule, 5 (five) x 5mg ampoules DOSE mg as directed in anticipation of pain Signature of Doctor The Doctor Date Date For dispenser No. of Prescns. on form QCP The Practice Lincoln LINCOLN 830 NH PATIENTS please read the notes overleaf FP10NC 0899 This is a guide for dispensing quantities only, not dosages; please see latest edition of the Palliative Care Formulary, Palliative Adult Network Guidelines (PANG) (available at http://book.palliative.info/) or the Liverpool Care Pathway symptom control sheets for breakthrough doses to write on CD1 form. If patient is already taking this medication orally then the quantity and strength of medication left in the home needs to be individualised and reviewed regularly to ensure correct dose available for parenteral administration. Page 25 of 31

Appendix 8 Equality Analysis Introduction The general equality duty that is set out in the Equality Act 2010 requires public authorities, in the exercise of their functions, to have due regard to the need to: Eliminate unlawful discrimination, harassment and victimisation and other conduct prohibited by the Act. Advance equality of opportunity between people who share a protected characteristic and those who do not. Foster good relations between people who share a protected characteristic and those who do not. The general equality duty does not specify how public authorities should analyse the effect of their existing and new policies and practices on equality, but doing so is an important part of complying with the general equality duty. It is up to each organisation to choose the most effective approach for them. This standard template is designed to help LCHS staff members to comply with the general duty. Please complete the template by following the instructions in each box. Should you have any queries or suggestions on this template, please contact Qurban Hussain Equality and Human Rights Lead. Page 26 of 31

Equality analysis Title: Policy for Pre-emptive Prescribing and Supply of Palliative Care Medications for Adults Relevant line in: Palliative and end of life care What are the intended outcomes of this work? Include outline of objectives and function aims The purpose of this Policy is to: Implement a standard of quality care across Lincolnshire which includes pre-emptive prescribing for distressing symptoms Provide pre-emptive prescribing and rapid access to medicines commonly prescribed in palliative care by ensuring a small stock of palliative care medications has been prescribed, dispensed and placed in the patient s home Support effective team working between doctors, nurses and pharmacists, both in and out of normal working hours Define the process for accessing palliative care medication Improve prompt access to symptom control for patients who are dying Contribute to the reduction in emergency admissions for these patients and support patients who choose to die at home Who will be affected? e.g. staff, patients, service users etc Staff, patients and carers. Evidence The Government s commitment to transparency requires public bodies to be open about the information on which they base their decisions and the results. You must understand your responsibilities under the transparency agenda before completing this section of the assessment. What evidence have you considered? List the main sources of data, research and other sources of evidence (including full references) reviewed to determine impact on each equality group (protected characteristic). This can include national research, surveys, reports, research interviews, focus groups, pilot activity evaluations etc. If there are gaps in evidence, state what you will do to close them in the Action Plan on the last page of this template. This SOP supports staff, patients and carers to prepare for the terminal phase of illness and supports patients who choose to die at home. Within Lincolnshire, the health care community is committed to the delivery of palliative and end of life care in a non-discriminatory way to ensure equity of access to high quality services. Disability Consider and detail (including the source of any evidence) on attitudinal, physical and social barriers. N/A Sex Consider and detail (including the source of any evidence) on men and women (potential to link to carers below). N/A Race Consider and detail (including the source of any evidence) on difference ethnic groups, nationalities, Roma gypsies, Irish travellers, language barriers. N/A Age Consider and detail (including the source of any evidence) across age ranges on old and younger people. This can include safeguarding, consent and child welfare. N/A Gender reassignment (including transgender) Consider and detail (including the source of any evidence) on transgender and transsexual people. This can include issues such as privacy of data and harassment. N/A

Sexual orientation Consider and detail (including the source of any evidence) on heterosexual people as well as lesbian, gay and bi-sexual people. N/A Religion or belief Consider and detail (including the source of any evidence) on people with different religions, beliefs or no belief. N/A Pregnancy and maternity Consider and detail (including the source of any evidence) on working arrangements, part-time working, infant caring responsibilities. N/A Carers Consider and detail (including the source of any evidence) on part-time working, shift-patterns, general caring responsibilities. N/A Other identified groups Consider and detail and include the source of any evidence on different socio-economic groups, area inequality, income, resident status (migrants) and other groups experiencing disadvantage and barriers to access. N/A Engagement and involvement Was this work subject to the requirements of the Equality Act and the NHS Act 2006 (Duty to involve)? No How have you engaged stakeholders in gathering evidence or testing the evidence available? This work was led by a multi-professional group with representation from LCHS, ULHT, pharmacy and Marie Curie Cancer Care. Wider consultation through the Lincolnshire Palliative and End of Life Care Collaborative Forum has taken place. How have you engaged stakeholders in testing the policy or programme proposals? Consultation with all stakeholders in Lincolnshire. For each engagement activity, please state who was involved, how and when they were engaged, and the key outputs: Circulation to key organisations/stakeholders via email for comments on the draft policy. User engagement through the Lincolnshire Palliative and End of Life Care Collaborative Forum. Summary of Analysis Considering the evidence and engagement activity you listed above, please summarise the impact of your work. Consider whether the evidence shows potential for differential impact, if so state whether adverse or positive and for which groups. How you will mitigate any negative impacts. How you will include certain protected groups in services or expand their participation in public life. The work undertaken will ensure consistency across the county and equity of rapid access to medicines commonly used in palliative care. Now consider and detail below how the proposals impact on elimination of discrimination, harassment and victimisation, advance the equality of opportunity and promote good relations between groups. Eliminate discrimination, harassment and victimisation Where there is evidence, address each protected characteristic (age, disability, gender, gender reassignment, pregnancy and maternity, race, religion or belief, sexual orientation). N/A Advance equality of opportunity Where there is evidence, address each protected characteristic (age, disability, gender, gender reassignment, pregnancy and maternity, race, religion or belief, sexual orientation).

N/A Promote good relations between groups Where there is evidence, address each protected characteristic (age, disability, gender, gender reassignment, pregnancy and maternity, race, religion or belief, sexual orientation). N/A What is the overall impact? Consider whether there are different levels of access experienced, needs or experiences, whether there are barriers to engagement, are there regional variations and what is the combined impact? N/A Addressing the impact on equalities Please give an outline of what broad action you or any other bodies are taking to address any inequalities identified through the evidence. N/A Action planning for improvement Please give an outline of the key actions based on any gaps, challenges and opportunities you have identified. Actions to improve the policy/programmes need to be summarised (An action plan template is appended for specific action planning). Include here any general action to address specific equality issues and data gaps that need to be addressed through consultation or further research. N/A Please give an outline of your next steps based on the challenges and opportunities you have identified. Include here any or all of the following, based on your assessment Plans already under way or in development to address the challenges and priorities identified. Arrangements for continued engagement of stakeholders. Arrangements for continued monitoring and evaluating the policy or service for its impact on different groups as the policy\service is implemented (or pilot activity progresses) Arrangements for embedding findings of the assessment within the wider system, other agencies, local service providers and regulatory bodies Arrangements for publishing the assessment and ensuring relevant colleagues are informed of the results Arrangements for making information accessible to staff, patients, service users and the public Arrangements to make sure the assessment contributes to reviews of DH strategic equality objectives. For the record Name of person who carried out this assessment: Date assessment completed: 020216 Name of responsible Director/Director General: Date assessment was signed:

Action plan template This part of the template is to help you develop your action plan. You might want to change the categories in the first column to reflect the actions needed for your policy. Category Actions Target date Person responsible and their Directorate Involvement and consultation Data collection and evidencing Analysis of evidence and assessment Monitoring, evaluating and reviewing Transparency (including publication)

Appendix 9 NHSLA Monitoring Template Minimum requirement to be monitored Process for monitoring e.g. audit Responsible individuals/ group/ committee Frequency of monitoring/audit Responsible individuals/ group/ committee (multidisciplinary) for review of results Responsible individuals/ group/ committee for development of action plan Responsible individuals/ group/ committee for monitoring of action plan Pre-emptive prescribing in place when required? If no, Responsive Needs Tool level prior to medication being required? If no, were drugs available and obtained from the community pharmacy? How often was OOH stock used and why? Part of the annual CD audit LCHS Medicines Optimisation Group Annual LCHS Medicines Optimisation Group + Lincolnshire Palliative and End of Life Care Collaborative Forum Lincolnshire Palliative and End of Life Care Collaborative Forum Lincolnshire Palliative and End of Life Care Collaborative Forum + LCHS Medicines Optimisation Group