End of life care planning and medicines optimisation

Care planning and communication are central to safe management of medicines for people during end of life care.

The lead for care planning will depend on where the person lives but would usually be their GP. In some cases, hospice teams may be involved in the care planning. They may provide prescribing input or specialist advice.

Anticipatory prescribing

Anticipatory prescribing is the prescribing of medicines before a person needs them. Anticipatory medicines may be supplied through a just in case (JIC) scheme. This allows prescribing of small quantities of appropriate medicines on an individual basis. It usually follows local policies and formularies.

Care providers should be aware of local schemes to access anticipatory medicines. This includes outside of normal working hours.

If medicines are pre-supplied there must be personalised administration directions from the prescriber (authorisation to administer). There should be clear prescriber’s directions for care staff and healthcare professionals. They should include the current dose to be administered. The directions should be regularly reviewed by the prescriber.

If the dose has changed from the original prescription and medicine label, you do not need to replace the medicines if they have not expired. Update care plans and medicines records to reflect the current dose.

Care at home - Before storing medicines in a person’s home, a risk assessment should be carried out. This should include record keeping and how to store medicines.

Care homes- controlled drugs must be stored securely, and registers maintained. Find out more about storing controlled drugs in care homes.

In the last days of life

In the last days of life, a person’s current medicines will usually be reviewed by a healthcare professional involved in their care. Before stopping or changing any medicines, options will be discussed with the person or carer. This should include considering if the person can swallow safely.

Decisions made should be recorded in the care plan.

Symptom control

Medicines optimisation is important in effective symptom control. A person-centred approach considers:

• the likely cause of the symptom
• the person’s preferences
• interactions with other medicines or conditions
• if the person's regular medicines are still required.

Medicines are usually prescribed to manage pain, nausea and vomiting, secretions and agitation. These can include controlled drugs.

If 'when required' PRN medicines are prescribed, it must be clear what they are being used for. For example, you could use morphine sulphate oral solution for pain or breathlessness. Clear guidance should be in place. This will help staff administer PRN medicines safely and effectively. Guidance should be reviewed as needed.

It must be clear from the administration records what dose has been given. Find out more about PRN medicines.

When staff administer these medicines, they should record whether they are effective. They should check for side effects. Staff should give feedback to the prescriber about the effects of these medicines. This should be in line with the person's care plan.

Healthcare professionals from outside the care home may visit to administer medicines. Care home staff should keep a record of medicines administered by those professionals. Care home staff must update controlled drug registers when controlled drugs are given.

The care plan should include oral health care needs.

Syringe drivers

Syringe drivers are used to administer medicines subcutaneously. They may benefit patients who are unable to take oral medicines. In some cases, the local hospice can help with syringe drivers.

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

• check that medicines and solutions used to dilute them are compatible. Use a recognised source to check compatibility.
• use two separate syringe drivers if compatibility is an issue
• check that syringe drivers are adequately maintained
• be trained and competent before using a syringe driver
• be familiar with local policies, procedures and the pump used.

Once the syringe driver has started, it should be labelled and regularly checked in line with local policy.

The care plan should make it clear who to contact for help, including out of hours.

Controlled drugs

There should be robust procedures for safe and secure storage of a person's medicines. The processes should limit access to medicines to appropriate people. This is particularly important when dealing with controlled drugs. Keep appropriate and accurate records.

The procedure should include disposal/return of any unused medicines following national guidance.

It is good practice for two nurses or staff members to check and administer controlled drugs. This is not a legal requirement. Where staff do the second check, they should be trained and assessed as competent.

You should have robust systems in place to review incidents. Report and respond to any discrepancies within reasonable time limits. Policies should include the name and contact details of anyone who you need to inform. Include details of the relevant NHS Controlled Drugs Accountable Officer (CDAO) at NHS England.