Quality statement 3: Anticipatory prescribing

Quality statement

Adults in the last days of life who are likely to need symptom control are prescribed anticipatory medicines with individualised indications for use, dosage and route of administration.

Rationale

As a person approaches the last few days of their life, changes in their condition may lead to changes in existing symptoms, the emergence of new symptoms or changes in the person's ability to take medicines to manage their symptoms (such as swallowing oral medicines). Prescribing medicines in anticipation can avoid a lapse in symptom control, which could otherwise cause distress for the person who is dying and those close to them. The drugs prescribed must be appropriate to the individualised anticipated needs of the dying person and include written clinical indications (current or anticipated), dosage and routes of administration (some drugs may be prescribed for more than one indication at different doses).

Quality measures

Structure

Evidence of local arrangements to ensure that adults in the last days of life are assessed for likely symptoms and are prescribed anticipatory medicines.

Data source: Local data collection.

Process

a) Proportion of adults recognised as being in the last days of life who have their prescribing needs assessed for symptoms likely to occur in their last days of life.

Numerator – the number in the denominator whose prescribing needs have been assessed for symptoms likely to occur in the last days of life.

Denominator – number of adults recognised as being in the last days of life.

Data source: Local data collection based on audits of patient care records.

b) Proportion of adults recognised as being in the last days of life prescribed anticipatory medicines with individualised indications for use, dosage and route of administration.

Numerator – the number in the denominator with care records that show anticipatory medicines have been prescribed with individualised indications for use, dosage and route of administration.

Denominator – number of adults recognised as being in the last days of life.

Data source: Local data collection based on audits of patient care records.

Outcome

Proportion of adults who had their key symptoms controlled in the last days of life.

Data source: Local data collection based on audits of patient care records. National data on the proportion of people who died in hospital who had key symptoms that could be present around the time of death controlled are reported in the Royal College of Physicians' End of life care audit – Dying in hospital report for England.

What the quality statement means for different audiences

Service providers (such as hospitals, hospices and GP practices) ensure that systems are in place to assess adults in the last days of life for likely symptoms, to prescribe anticipatory medicines for the likely symptoms using an individualised approach, and to ensure access to medicines.

Healthcare professionals (such as secondary care doctors, specialist palliative care doctors, GPs, non-medical prescribers) assess what symptoms are likely to occur for a person in the last days of life and discuss what medicines might be needed with the dying person, those important to them, and other members of the team caring for them. They prescribe anticipatory medicines appropriate to the individual anticipated needs of the dying person, including indications for use, dosage and route of administration.

Commissioners (such as clinical commissioning groups) use contractual and service specification arrangements to ensure that providers prescribe anticipatory medicines using an individualised approach for adults in the last days of life and ensure access to medicines.

Adults who are in the last days of life are prescribed medicines in advance for symptoms that might happen in the future. This avoids a delay in getting medicines that might be needed quickly when symptoms develop. These medicines are prescribed based on the individual needs of the person.

Source guidance

Care of dying adults in the last days of life (2015) NICE guideline NG31, recommendation 1.6.1

Definitions of terms used in this quality statement

Anticipatory medicines

Medication prescribed in anticipation of symptoms, designed to enable rapid relief at whatever time the patient develops distressing symptoms. Drugs prescribed in anticipation may include previous or current prescriptions, sometimes with a change in the route of administration, and newly prescribed drugs for anticipated new symptoms.

[NICE's guideline on care of dying adults in the last days of life, full guideline and expert opinion]