Quality standard
Quality statement 3: Anticipatory prescribing
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
The following measures can be used to assess the quality of care or service provision specified in the statement. They are examples of how the statement can be measured, and can be adapted and used flexibly.
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: Data can be collected locally by healthcare professionals and provider organisations, for example using 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: Data can be collected locally by healthcare professionals and provider organisations, for example using audits of patient care records. The National Audit of Care at the End of Life: dying in hospital collects information for patients who died in hospital on whether anticipatory medication was prescribed for symptoms likely to occur in the last days of life and on whether the medication was individualised.
Outcome
Proportion of adults who had their key symptoms controlled in the last days of life.
Data source: Data can be collected locally by healthcare professionals and provider organisations, for example using audits of patient care records.
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 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. NICE guideline NG31 (2015), 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 full guideline on care of dying adults in the last days of life and expert opinion]