Anticipatory Prescribing (AP) is the prescribing of injectable medications for community end of life care in advance of need, to ensure that appropriate medication is readily available should troubling symptoms arise in the final phase of life. We conducted a web-based survey in April 2020 to investigate clinicians’ experiences concerning changes in AP during the COVID-19 pandemic and their recommendations for change; we are now conducting follow up interviews to have a more in-depth understanding of those changes.
Anticipatory prescribing (AP) is the prescribing and dispensing of injectable medications in advance of clinical need, for visiting nurses or doctors to give as required if symptoms (pain, nausea and vomiting, agitation and respiratory tract secretions and breathlessness) arise in the final days of life.
Recent UK guidance proposed both family caregiver administration and use of different drug formulations via the buccal, rectal or sublingual routes along with traditional subcutaneous injections. The evidence base for current AP practice is sparse, even more so for the buccal or sublingual routes, which are based primarily on professional experience and within paediatric palliative care.
Family caregivers have rarely administered AP medications in the UK. Australian experience suggests family caregivers appreciate being able to provide symptom relief but some struggle with the responsibility.
We aimed to investigate UK and Ireland clinicians’ experiences concerning changes in AP practice during the COVID-19 pandemic and their recommendations for change, namely:
Phase I - web-based survey:
1. Changes in drug prescription?
2. Changes in drug administration?
3. Changes in support structures for AP?
4. Suggestions for further changes?
Phase II – follow up interviews
1. what changes remain
2. what has gone back to being as it was prior to the pandemic
3. What are any recommendations on AP practice?
4. How do you see the practice of AP in the future?
We are in the process of conducting the follow up interviews to learn about the experiences of healthcare professionals in this matter, in a more in-depth way.
Potential or actual impact
The results of the web-based survey have been published. We aim to publish another paper on the results of the follow interviews.
We wrote guidance for EOLC prescribing for the Cambridgeshire and Peterborough Clinical Commissioning Group in May 2020: this was taken up by several other CCGs across the country and posted on the website of the Royal College of General Practitioners.
We aim to develop recommendations for safe AP practice.
Papers/resources associated with this study
Antunes B, Bowers B, Winterburn I, Kelly M, Brodrick R, Pollock K, Majumder M, Spathis A, Laurie I, George R, Ryan R, Barclay S. (June 2020). “The changing landscape of anticipatory prescribing practice in community end-of-life care in the United Kingdom during the COVID-19 pandemic: online survey”. BMJ Supportive and Palliative Care; 10: 343–349. Access here
Presentation at Hospice UK Zoom ECHO sessions on the 8th of July 2020
Bowers B, Pollock K, Barclay S. (April 2020). “Administration of end-of-life drugs by family caregivers during covid-19 pandemic. Doing this safely needs training, support and careful prescribing”. British Medical Journal: 369: m1615. Access here
Analysis and publication of data collected in Phase II, the follow up interviews.Depending on how the pandemic evolves, we may further conduct another study on this topic.
We have two PhD colleagues in the Cambridge research group working on AP in the community: Ben Bowers and Megha Majumder.
Who is involved?
Researchers and institutions
Prof Stephen Barclay, Dr Bárbara Antunes, Ben Bowers, Joshua Gallagher: members of the University of Cambridge Primary Care Unit’s Palliative and End of Life Care research group.
Prof Stephen Barclay