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Optimising medicines during end of life care

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During end of life care, one clinician should be responsible for a person’s medicines.

This will depend on where the person lives but would usually be their GP. In some cases, hospice teams may give support.

Symptom control

Medicines optimisation is important in effective symptom control. A person-centred approach takes into account:

  • the likely cause of the symptom
  • the person’s preferences
  • interactions with other medicines or conditions

Maintain clear guidance or protocols. Review them when needed. These help staff to administer 'when required' or PRN medicines safely and effectively.

When PRN medicines are prescribed, it must be clear what they are being used for. For example, you could use morphine sulfate oral solution for pain or breathlessness. It must be clear from the administration records what dose has been given. Find out more about PRN medicines.

If symptoms are poorly controlled, care home staff should contact the prescriber.

Healthcare professionals from outside the home may visit a person to administer medicines. Care home staff should keep a record of medicines administered by those professionals. When appropriate, the care home staff should update the controlled drug registers.

Anticipatory prescribing and just in case boxes or bags (JICs)

'Just in case' (JIC) medicines are prescribed in advance of a person needing them.

JIC schemes anticipate common symptoms. Small quantities of appropriate medicines are prescribed for a person. These are stored in a special container in their home

Keep a list of local pharmacies which stock these medicines. Make sure staff know how to find this information, in case they need access to the medicines out of hours.

Assess the risk before storing JIC bags. Store controlled drugs securely and maintain registers. Find out more about storing controlled drugs in care homes.

Keep a record of any schedule 2 controlled drugs in the JIC bag on a record sheet. You should usually keep this record sheet with the bag. You also need to record them in the care home controlled drugs register.

When staff administer these medicines, they should check for benefit and side effects. Staff should give feedback to the prescriber about these.

In the last days of life

Review current medicines in the last days of life. You must do this together with a healthcare professional. Consider stopping medicines that are not providing symptomatic relief. Before stopping any medicines, discuss options with the person or carer. Take account of the person's ability to swallow safely. Consider how people tolerate oral medicines.

Record decisions in the care plan.

Include mouth care in the care plan. This may include artificial saliva products.

Syringe pumps

Syringe pumps administer medicines subcutaneously. They may benefit patients who are unable to manage or tolerate oral medicines. The pumps can be mains operated, for example if the person will stay in bed. Other pumps are battery powered so that the person can move around. In some cases, the local hospice can help with syringe pumps.

Where nurses providing social care are responsible (such as, in a nursing home), they should:

  • check that medicines used in a syringe pump are compatible with the diluent and with each other. If compatibility is an issue, you may need two syringe drivers
  • have access to a recognised source of information to check compatibility
  • check that syringe drivers have been maintained adequately. Ask for the last service date and documentation
  • be trained and competent before using a syringe driver. They must be familiar with local policies and procedures

Once commenced, label and check the syringe driver. Do this as agreed in your local policy and the person's care plan. The care plan should make it clear who to contact for help, including out of hours.

Controlled drugs

You should have robust processes for safely and securely storing a person's medicines. The processes should limit access to medicines to appropriate people. This is particularly important when dealing with controlled drugs. Maintain appropriate records.

It is good practice for two nurses or staff members to check and administer controlled drugs. This is not legally required.

You should have robust systems in place to review incidents. Regularly check staff competency and training. Report and respond to any balance discrepancies within reasonable time limits.

Last updated:
11 March 2019

 


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