Non-medical prescribing in palliative care
This month's roundup will present some of the latest independent prescribing research in palliative care prescribing. This is a complex speciality where patients frequently have multiple comorbidities, and opioid prescribing is common. To establish the most recent literature in the area, a search of CINAHL and MEDLINE databases was conducted, which yielded five publications (Bowers and Redsell, 2017; Hall, Thompson, Phair, and Davies, 2019; Latham and Nyatanga, 2018a, 2018b; Ziegler, Bennett, Mulvey, Hamilton and Blenkinsopp, 2018).
Characterising the growth in palliative care prescribing 2011–2015: analysis of national medical and non-medical activity
In this study, routinely collected data were analysed to investigate the growth in nurse and pharmacist prescribing from April 2011 to April 2015 in England. During the study period, non-medical prescribers (NMP) were responsible for around 6.7% of prescriptions issued in community palliative care. Comparisons were made between medical and non-medical prescribers and an overall growth of 32% was reported in prescriptions over the study period, with an annual 28% increase in drugs prescribed by NMP. Analysis of the types of drug prescribed by NMP revealed an increase in opioid prescribing of around 30% each year and smaller increases in nonopioid prescribing of between 10 and 32%. Opioid prescribing by medical prescribers remained unchanged. This suggests that changes to the misuse of drugs act in 2012, permitting more liberal opioid prescribing (HMSO, 2015), have had a direct impact on end-of-life care, which may have improved the quality of care provided to this population.
A qualitative study of community nurses' decision-making around the anticipatory prescribing of end-of-life medications
This exploratory qualitative study sampled palliative care nurses and district nurses (n =11) working in the community who prescribed anticipatory care medication for people nearing the end of life. It sought to establish the decision-making process when prescribing anticipatory medicines. Data were collected using semi-structured interviews and thematically analysed. Three themes were identified; drugs as a safety net, reading the situation and playing the game. With regards to using drugs as a safety net, prescribers believed it to be important to prescribe anticipatory drugs to cover out of hours, providing reassurance for families and patients. Participants used their judgement to assess a good time to introduce anticipatory medications and shared decision-making was central to this. This required establishing a rapport with the patient and family to establish when the time was right. Yet some voiced that, sometimes, there was not enough time to fully discuss options. The final theme ‘playing the game' concerned the interaction between the prescriber and General Practioner (GP). The data suggested that, whilst GPs trust the judgment of the nurse, there was concern amongst some participants that anticipatory medication may be prescribed too early and used inappropriately. Keeping in close contact with a GP appeared to mitigate this. This study suggests that nurses are well-placed to have conversations with the dying patient about anticipatory medicines and central to this process is establishing rapport with the patient, family and the GP. This approach fosters shared decision-making and seeks to avoid inappropriate prescribing.
Community palliative care clinical nurse specialists as independent prescribers
This qualitative study, presented in two papers applied interpretative phenomenological analysis to carry out an in-depth exploration of six community palliative care nurse specialists' prescribing practice. Five themes emerged from the semi-structured interviews consisting of benefits of, and barriers to, prescribing, the impact of the role, reflections on the prescribing course, and views about recommending the role to others. The benefits identified supported the theory that changes in legislation have improved access to medicines. This study reported all six participants thought their prescribing role had improved symptom management, access to medicines out of hours and provided a more holistic approach to palliative care nursing. Professionally, participants felt better informed about pharmacology and therapeutics. However, there still was some anxiety about making a mistake, particularly when writing prescriptions in the patient's home. The data suggested a minority view that some colleagues were not aware of the range of medicines that nurse prescribers were authorised to prescribe, and that lack of access to notes impeded prescribers ability to make a fully informed prescribing decision. Nonetheless, the majority of participants felt that non-medical prescribing for palliative care patients saved time and, on completion of the course, they were fully prepared to undertake the role. This small scale in-depth exploration of prescribing practice echoes those reported in previous qualitative studies exploring benefits and barriers of nurse prescribing (Cleary, Kornhaber, Sayers and Gray, 2017; Latter, 2010). This suggests that, despite some anxiety about the role, the perceived benefit of prescribing to service users by nurse prescribers is evident in community palliative care.
Clinical nurse specialist prescribing in a cancer centre supportive and palliative care team
The final and most recent study presented a prospective service evaluation of three prescribers' activites over a three month period. The practitioners recorded all prescribing activity including decisions not to prescribe. Of the 493 consultations that took place during the study period, 50% of those involved a prescribing decision, and in 6% of cases involved a deprescribing decision. Opioids accounted for over 40% of drugs prescribed, and many drugs were prescribed off-label for a clinically indicated symptom. This suggests that independent prescribing is an often-used intervention by palliative care nurses and pharmacists that expedites access to medicines at a crucial time in a person's life. The study concludes that it is a vital and valuable role for those working in palliative and end-of-life care, and one that should be encouraged.
Conclusion
This rapid review of prescribing in palliative care suggest that the frequency of prescribing in the area has grown since changes in legislation in 2012. The qualitative research reported in this roundup suggests that this increase in prescribing has a positive impact on access to medicines. The next steps may be to evaluate the quality of prescribing in this area against specific person centred outcomes.