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SUFFOLK WIDE JOINT GUIDELINE FOR THE PROVISION OF ‘JUST IN CASE’ MEDICATIONS
Document Reference No: 1715/ SCH CP51
Version No: 1.0 Status: Approved
Type: Clinical policy Document applies to (staff group):
All staff employed by the Suffolk Community Healthcare Consortium
Where the procedural documents refer to Suffolk Community Healthcare (SCH) this is referring to those staff employed by the Suffolk Community Healthcare Consortium; a service delivered by West Suffolk NHS Foundation Trust (WSHFT) with The Ipswich Hospital NHS Trust (IHT) and Norfolk Community Healthcare and Care Trust (NCH&C) This guidance has been developed in response to local demand from community providers via the Suffolk End of Life Steering group. The process for providing and managing just in case medications is currently erratic with a wide range of arrangements and provision from all healthcare providers in Suffolk. The guidance will ensure an equitable and safe process for the provision of Just in Case medications. This guidance has been developed jointly by Suffolk Community Healthcare, a Suffolk Macmillan GP representative GPs, St Elizabeth Hospice and St Nicolas Hospice This document provides guidance on the type, dosage and mechanism of prescribing ‘just in case medication‘, with the aim of avoiding distress caused by limited access to medications for symptom control at the end of life. The guidance aims to give consistency across care settings and provide a framework for audit and quality improvement. Responsibility for ensuring compliance will rest with each provider organisation such as GP surgery, Suffolk Community Health Care, Hospice and Hospital. An overview of compliance will be via the Suffolk End of Life Care Group. Suffolk Community Healthcare will be responsible for ensuring compliance for community patients with support from GP surgeries, Hospital and Hospice in assessing compliance with their input. Compliance will be assessed with audit. The guidance will be disseminated across all service via their own governance arrangements. Resources required are Red CD storage bags. There are no identified associated audits. This policy applies to all staff working with end of life patients within acute and community sectors Date adopted/ ratified:
March 2017
Review date:
March 2020
Signature of Director:
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SUFFOLK WIDE JOINT GUIDELNE FOR THE PROVISION OF ‘JUST IN CASE’ MEDICATIONS
Policy Reference: SCH CP51 Version: 1.0 Status: Approvedl
Document applies to: All services within the Suffolk Community Healthcare Consortium; a service delivered by West Suffolk NHS Foundation Trust (WSHFT) with The Ipswich Hospital NHS Trust (IHT) and Norfolk Community Healthcare and Care Trust (NCH&C)
Required compliance: This policy must be complied with fully at all times by the appropriate staff. Where it is found that this policy cannot be complied with fully, this must be notified immediately to the owner through the waiver process
Document owner: Executive Chief Nurse, West Suffolk Hospital Foundation Trust Document authors: Head of Nursing & Professional Practice, Suffolk End of Life
Steering Group Other contact: District Nurse Development Lead Date this version adopted March 2017 Reviewer New policy Last review date N/A Next review date March 2020 Location of electronic master SCH “S” Drive
Location of staff accessible copy SCH Intranet
AGREED POLICY/GUIDELINE REVIEW / RATIFICATION / ADOPTION PATH:
Level 1: Agreed by: End of Life Steering Group Date: January 2017
Level 2: Agreed by: Integrated Policy & Documentation Group Date: March 2017
Level 3: Agreed by: Quality & Patient Safety Assurance Group Date:
Name and Title of people who carried out the EQIA: Fiona Whitfield, Head of Nursing & Professional Practice
Name of Director who signed EQIA: Rowan Procter
Date EQIA completed: March 2017
Signature of Director:
Date EQIA signed: 29/7/17
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CONTENTS 1 Introduction and purpose .................................................................................................................... 4
2 Objectives .......................................................................................................................................... 5
3 Development of this policy .................................................................................................................. 5
4 Definitions and Terminology ................................................................................................................ 5
5 Policy agreement path......................................................................................................................... 6
6 Roles and Responsibilities .................................................................................................................... 6
7 Cross-reference to other related policies .............................................................................................. 6
8 Guidance: Inclusions and Exclusions ..................................................................................................... 7
9 Guidance on Non-professionals giving symptom control medication ....................................................... 8
10 Prescription ........................................................................................................................................ 9
11 Recommended drugs for anticipatory phase ......................................................................................... 9
12 Recommended dose ranges for the active phase ................................................................................. 10
13 How to prescribe .............................................................................................................................. 11
14 Supply of prescription medications ..................................................................................................... 11
15 Storage of Medications...................................................................................................................... 11
16 Coordinating ‘Just in Case Medication’ use.......................................................................................... 12
17 Administration of medications ........................................................................................................... 12
18 Disposal ........................................................................................................................................... 12
19 Training and Competency/ Increasing Awareness ................................................................................ 13
20 Audit ................................................................................................................................................ 13
21 Appendices ....................................................................................................................................... 13
Appendix 1: Processes for set-up of a Just in Case Prescription .......................................................................... 15
Appendix 2: Opioid Conversion Chart .............................................................................................................. 16
Appendix 3: Pre-populated Community Nursing Prescription Sheets .................................................................. 17
Appendix 4: Ipswich Hospital Evolve Drug administration charts ........................................................................ 24
Appendix 5: Content of ‘Just in Case’ bag ......................................................................................................... 30
Appendix 6: Clinical roles and responsibilities ................................................................................................... 31
Appendix 7: ‘Just in Case’ bag audit proforma .................................................................................................. 34
Appendix 8: Patient information leaflet ........................................................................................................... 36
Appendix 9: Generic letter to inform ‘Just in Case’ medications have commenced .............................................. 37
Appendix 10: Ipswich Hospital ward check list .................................................................................................. 38
Appendix 11:‘Just in Case’ one sheet summary ................................................................................................. 39
Equality Impact Assessment Tool .................................................................................................................... 40
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EQUALITY and DIVERSITY IMPACT STATEMENT
All policies, procedures, guidelines and other approved documents of the SCH Consortium are formulated to comply with the overarching requirements of legislation, policies or other overarching standards relating to equality and diversity The SCH Consortium welcomes feedback on this document and the way it operates and needs to be informed of any possible or actual adverse impact that it may have on any groups listed below. This document has been screened to determine equality relevance for the following dimensions: * Age * Gender * Disability * Race * Religion/ belief * Sexual Orientation * Transgender/ transsexual * Other characteristics
1 Introduction and purpose
1.1. Patients reaching the end of their lives may experience new or worsening symptoms for which they require urgent medication. It is essential that these patients, and the health care professionals looking after them, have easy, prompt access to medication that can help them if their condition deteriorates suddenly, at any time of day or night.
1.2. This policy describes a process for enabling ‘pre-emptive’ or ‘just in case’ availability of medications in a patient’s home and aims to reduce delays at the time of need. Patients near the end of life may have impaired ability to swallow hence medication often needs to be administered subcutaneously.
1.3. This process for ensuring medication is available does not remove the potential necessity of obtaining urgent medical or nursing review. Access to symptom control medications, proactive management of symptoms and anticipation of patient’s future needs are key components of:
a) Department of Health National End of Life Care Strategy, 2008
b) Gold Standards Framework, control of symptoms and care in the dying phase
c) Improving Supportive and Palliative Care for Adults with Cancer – NICE Guidance 2004
d) Department of Health Guidance, Securing Proper Access to Medicines in the Out of Hours Period 2004
e) BMA Guidance, Focus on Anticipatory Prescribing for End of Life Care, GPC April 2012
f) One chance to get it right: improving people’s experience of care in the last few days and hours of life. June 2014-Leadership Alliance for the Care of Dying People
1.4. Publications have also highlighted the need for guidance to ensure that symptom control medication is used appropriately, proportionately, in discussion with patient/family and in response to a direct need rather than as a matter of routine practice. These include:
a) More care, less pathway: a review of the Liverpool Care Pathway. Neuberger J, 2013
b) One chance to get it right: improving people’s experience of care in the last few days and hours of life. June 2014-Leadership Alliance for the Care of Dying People
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2 Objectives
2.1. This policy aims to support patient choice if they wish to remain at their normal place of residence (e.g. home or nursing home) by:
a) Improving access to palliative care medications in the community
b) Avoiding the distress caused to patients, carers and health staff due to not having correct medicine readily available
c) Encouraging prescribers to anticipate common symptoms experienced by the dying, e.g. pain, secretions and agitation and prescribe sufficient quantities of the appropriate medication which is dispensed and kept in the patient’s home
d) Ensure prescribing complies with current legislation and takes place in a clear and safe manner that is understood by health care staff responsible for dispensing and administering the medication
e) Provide a safe framework for the use of palliative care medications in the home
f) Provide a framework against which standards can be assessed by audit
3 Development of this policy
3.1. This policy has been developed by request of the Suffolk End of Life Steering group in collaboration with the following organisations:
a) Suffolk Community Healthcare
b) Ipswich Hospital NHS Trust
c) St Elizabeth Hospice
d) St Nicholas Hospice
e) West Suffolk NHS Foundation Trust
f) Ipswich and East Suffolk CCG
g) West Suffolk CCG
h) Out of Hours GP services
i) East Of England Ambulance trust
4 Definitions and Terminology
4.1. Just in case medication
Patients near the end of their lives are at risk of developing new or worsening symptoms out of normal GP practice hours. The types of symptoms that can occur are predictable and include pain, shortness of breath, nausea and vomiting, agitation and excess secretions. A set of ‘just in case medications’ aimed at relieving these symptoms can help to avoid distress caused by limited or delayed access to medication when needed. As the name ‘just in case’ implies they may not be needed but having them available, with appropriate explanation to the patient and family, can help health professionals to control any symptoms that do occur. A number of other terms can be used to describe these medications including ‘pre-emptive’ or ‘anticipatory’ medications. The term ‘just in case medication’ will be used for the purposes of this policy.
4.2. End of life care plan
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This is a documented care plan in any format that helps all those with advanced, progressive, incurable illness to live as well as possible until they die. It enables the supportive and palliative care needs of both patient and family to be identified and met throughout the last phase of life and into bereavement. It includes management of pain and other symptoms and provision of psychological, social, spiritual and practical support. A well-constructed plan of care for the end of life allows for potential improvement in a patient’s condition.
4.3. Key Worker
“a person who, with the patient’s consent and agreement, takes a key role in co-ordinating the patient’s care and promoting continuity, ensuring the patient knows who to access for information and advice” (NICE 2004)
4.4. Anticipatory and active phases in end of life care
For the purposes of this policy a distinction is made between an anticipatory phase where established management adequately controls the person’s symptoms, and an active phase where death is likely in a matter of days and no acute intervention is planned or required. It is difficult to define exact time scales but ‘just in case medication’ would be appropriate in the anticipatory phase if a rapid deterioration could be expected and is often within the last 2-3 months of life. The active phase is where a deterioration in a patient’s condition has started and death is probable in the next few days or week.
5 Policy agreement path
This policy has been ratified via the governance process in every organisation who intends to use it and the Suffolk End of Life Steering group following development by the Just in case medications Task and Finish group.
6 Roles and Responsibilities
6.1. The roles and responsibilities for the use of this policy are to ensure all key stakeholders follow the patient pathway across organisations in Suffolk. All healthcare workers work within their own scope of professional practice and competence as per their organisational policies and guidelines.
6.2. All organisations and staff must work together to ensure:
a) The most recent version of the policy should be kept updated and available
b) Staff have read and understood the policy
c) Training and competencies appropriate to staff roles are assessed and organised by each organisation
d) Report of all incidents and near misses within their own governance framework
e) All leaflets, charts and equipment are available
f) Prescription is prompt and correct to ensure the safety of patients and carers
g) Provide clear instructions and effective communication to patients/relatives
h) Recording of all actions and medications prescribed and given according to organisation procedures
i) The role specific guidance in the appendices 6 is followed
7 Cross-reference to other related policies
• Consent to Treatment Policy
• Controlled Drugs Policy
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• McKinley Syringe Pump Policy
• Incident Policy
• Mental Capacity Act
• Verification of Expected Death Policy
• Individual End of Life Care Plan
• End of life guideline
• Norfolk and Suffolk Joint Protocol for the Safe and Effective Disposal of both Pharmaceutical and Illicit Controlled Drugs when dealing with the deceased
8 Guidance: Inclusions and Exclusions
8.1. Inclusion Criteria and guidance
a) Patients registered with a GP within Ipswich and East Suffolk and West Suffolk CCGs (excluding Waveney CCG).
b) Patients for whom a ‘just in case’ prescription is planned, should be on a Gold standard Framework/palliative care register and have support by a District Nurse and the opportunity of support by clinical nurse specialist in palliative care.
c) There is no single, ideal time at which to prescribe ‘just in case medication’ as many factors need to be considered, but strong consideration should be given to prescribing if the prognosis is likely to be less than 3 months (e.g. most patients deemed eligible for fast track NHS continuing health care), where the condition is unpredictable or for those living in isolated situations or during extended holiday periods
d) The risk and benefits of providing these drugs needs to be assessed for every case.
e) Caution is needed with unusual drugs in current use e.g. methadone. Additional guidance can be obtained from Palliative Medicine Consultants if required
f) A lower threshold for prescription of ‘just in case medication’ should be considered for patients not wishing to leave home under any circumstances for healthcare treatment.
g) The medications and process in this policy are applicable to all community patients including those being discharged from acute care (hospital and hospice).
8.2. Cautions
a) Caution should be used for patients where there is a history or suspicion of drug misuse among family members, carers or visitors to the house. Although patients in these circumstances may not be able to have ‘Just in Case medications’ in the home, they should still receive appropriate medication when needed
b) Patients who are themselves unwilling to participate, such as those who have refused advanced care planning or where patient and/or carers have misinterpreted anticipatory prescribing as provision for euthanasia although good communication, reassurance and explanation should allay any fears.
8.3. Prescribing of ‘just in case’ pro re nata (prn) drugs
a) Patients who meet the criteria must have PRN drugs prescribed as a minimum within 24 hours of the identified need. The dosage instructions of these drugs should be reviewed regularly, at least every 4-6 weeks and in the event of any clinical change.
b) Medication stock should be replenished in advance of need. Responsibility for review should be confirmed between the GP, community nursing service or prescriber (if not GP). Whilst ultimate responsibility will rest with the GP this requires adequate handover of the prescription from any other prescriber.
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8.4. Prescribing of anticipatory drugs for syringe pumps
a) Syringe pump drugs must be prescribed only when the need has been identified, in the acute phase. The prescriber must ensure previous doses and medications are considered when deciding the correct dosage.
b) Please remember to check compatibilities especially when using more than 3 drugs and see local syringe pump policy for details. The dosage instructions of these drugs should be reviewed regularly in the event of any clinical change.
c) Responsibility for review should be confirmed between the GP, community nursing service or prescriber (if not GP). Whilst ultimate responsibility will rest with the GP this requires adequate handover of the prescription from any other prescriber.
d) Prescription of syringe pumps should only be for a patient who is known to the GP and under regular review. Prescription of a ‘just in case’ syringe pump in the anticipatory phase is not advised. Many people can, and do die without the need for continuous medication via a syringe pump.
e) Please remember to review their usual medication and discontinue drugs as appropriate e.g. a modified release oral opioid.
9 Guidance on Non-professionals giving symptom control medication
9.1. The person administering the medication such as patient, supporting family member or unpaid carer should be assessed for suitability. The results of any risk assessment should then be recorded in the patient record. The health professionals (e.g. community nurse and doctor) are responsible for ensuring that the carer understands the medication, when to use it, when not to use it and to review medication use regularly.
9.2. The assessment should include consideration of:
a) Patient / family member / carer’s mental capacity and probity
b) Patient / family member / carer’s competency e.g. if the medication is administered via an injection, the person should be assessed as competent to do so safely or ability to open medicine containers
c) The patient’s medical history, any known drug misuse or severe mental health conditions.
d) The type, dose and route of the medication
e) The relative risks and benefits of administering the medication or the medication not being administered in a timely manner. E.g. a patient in an isolated area not being able to get timely analgesia unless given by a relative
9.3. During the assessment the following points should be explained and documented:
a) Patient, family or carers can withdraw their consent at any time.
b) The person administering medication can also seek telephone advise prior to giving the medication if they have any uncertainty
c) If the person administering medication is planned to be away – plans needs to be in place to clarify who is to administer the medication safely.
d) Any information given and supervision should be tailored to individual need.
e) A referral to a pharmacist for a review may be required regarding any concerns about compliance aids, poly pharmacy, and concordance.
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f) There should be discussion concerning the risk of a patient deteriorating after a medication is given. When medication is given to patients because of symptoms that may occur during the dying process, death may occur shorty after a drug is given. Discussion should include this possibility and that appropriately given medication will not be causal in the death or deterioration. Such an event could cause significant distress and should be a consideration in helping to decide if the person is willing to administer the medication.
g) Whilst the registered nurse has a duty of care towards all patients, the registered nurse (and any doctor supporting the decisions) is not liable if a carer or patient makes a mistake whilst administering, as long as an careful risk assessment and competency assessment was carried out. In the event of a drug error appropriate actions must be taken to prevent re-occurrence of the incident (Nursing and Midwifery Council Standards for Medicine Management: NMC 2010)
10 Prescription
10.1. Before prescribing please decide if the patient is in the anticipatory phase or active phase and consider background doses of current medication.
10.2. The prescription should include medication for each of the following indications:
a) Pain (e.g. an opioid)
b) Nausea and vomiting (e.g. Levomepromazine)
c) Respiratory secretions or noisy breathing (e.g. Hyoscine butylbromide)
d) Agitation/anxiety (e.g. midazolam)
e) Shortness of breath (e.g. an opioid)
10.3. It is recommended that medicines are prescribed in a quantity that can be dispensed in the manufacturer’s original pack where possible. The aim is to provide sufficient medication to allow ‘as needed’ use and give time for a further prescription and collection of medicine. Additional medication may need to be provided close to holiday periods.
10.4. For processes for setting-up Just in Case prescriptions in both the Anticipatory & Active Phases please see appendix 1.
11 Recommended drugs for anticipatory phase
Medication Dose Strength/concentration Quantity (Suggested minimum)
Hyoscine butylbromide injection
20mg sc max 1 hourly for secretions
20mg/ml 10 x 1ml ampoules
Levomepromazine injection
6.25 to 12.5mg sc max 2 hourly for nausea/vomiting
25mg/ml 5 x 1ml ampoules
Midazolam injection 2.5 to 5mg sc max 1 hourly for agitation
10mg/2ml 10 x 2ml ampoules
Water for injection 10 x 10ml
If the patient is opioid naive
Diamorphine 2.5 to 5mg sc max 1 hourly
10mg ampoule 5 ampoules
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Oxycodone: If eGFR less than 30ml/min
2.5 to 5mg sc max 1 hourly
10mg/ml, 1ml ampoules
5 ampoules
Whilst oxycodone is preferred if the eGFR <30ml/min a switch is rarely needed above an eGFR of 30ml/min but consider if renal function is deteriorating rapidly. If no oxycodone is available the use of diamorphine is still acceptable with careful monitoring of the patient for side effects and consideration of a lower dose. If eGFR <15ml/min please discuss with a palliative care consultant
If the patient is already on an opioid
Calculate the total daily dose of opioid and divide by 6 for the prn dose. Remember to include transdermal opioid patches in PRN calculations, see opioid conversion chart in appendix 2. Ensure there is sufficient medication to meet 3-4 prn doses plus any regular doses for 2 days (or more if over an extended holiday period). If in the active phase ensure there is sufficient to allow a syringe pump to be started with an appropriate dose.
11.1. Other medication can be prescribed if there is a specific reason such as allergy, intolerance, patient preference or other clinical need such as known efficacy for a patient of another medication. Please note that Cyclizine and Buscopan (hyoscine butylbromide) are physically incompatible together in a syringe and best avoided together.
11.2. Key questions that all prescribers should consider are:
a) Is the patient opioid naïve?
• If not what is the background opioid: generally appropriate to continue this
• Is there a specific reason for one opioid e.g. previous intolerance of morphine and efficacy of oxycodone
b) If there known or likely organ dysfunction?
c) Are there other considerations such as
• Seizure management
• A high chance of an acute life-threatening event such as a bleed or airway obstruction?
12 Recommended dose ranges for the active phase
Examples of appropriate ranges for syringe pumps in the active phase (always use the lowest appropriate dose for the patient) Very large ranges are discouraged as significant changes in dose requirements strongly suggest the need for further clinical review. These are example ranges but different doses can be used if justified by clinical need PRN dose (SC) Syringe pump dose SC /24
hours Diamorphine (max 1 hourly) (Consider oxycodone if eGFR <30ml/min and discuss with the Hospice if <15)
1.25 to 2.5 mg
5 to 15mg (if opioid naïve, organ dysfunction, frailty or previous sensitivity)
Diamorphine 2.5 to 5mg (max 1 hourly) 10 to 30mg Diamorphine 5 to 10mg (max 1 hourly) 30 to 60mg Diamorphine 10 to 15mg (max 1 hourly) 60 to 90mg Diamorphine 15 to 20mg (max 1 hourly) 90 to 120mg Oxycodone 1.25 to 2.5mg (max 1 hourly) 5 to 15mg (if opioid naïve,
organ dysfunction, frailty or previous sensitivity)
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Oxycodone 2.5 to 5mg (max 1 hourly) 10 to 30mg Oxycodone 5 to 10mg (max 1 hourly) 30 to 60mg Oxycodone 10 to 15mg (max 1 hourly) 60 to 90mg Oxycodone 15 to 20mg (max 1 hourly) 90 to 120mg Levomepromazine 6.25mg (max 2 hourly 6.25 to 25mg Hyoscine butylbromide 20mg (max 1 hourly) 60 to 120mg Hyoscine butylbromide 20mg (max 1 hourly) 120-240mg Midazolam 2.5 to 5mg (max 1 hourly) 5 to 20mg Midazolam 5mg (max 1 hourly) 20 to 50mg (not generally
appropriate as starting dose unless seizure prophylaxis or established benzodiazepine use at high doses)
Midazolam 5 to 7.5mg (max 1 hourly) 50 to 70mg
13 How to prescribe
13.1. As well as a prescription to order the drugs from a pharmacy (e.g. FP10) the prescriber must write the subcutaneous anticipatory medicines on a community administration chart (see appendix 3) with clear instructions for the use of each medication including:
a) The medication name
b) The dose
c) The route
d) The frequency
e) Additional instructions such as indication for use and maximum dose in 24 hours can be included
f) Each entry must be signed and dated
13.2. Partly completed charts are provided in the appendices to help facilitate the most common prescriptions but it is the prescribers responsibility to ensure that the medication, dose and route is appropriate for that patient recognising any pre-existing opioid use and other medication.
13.3. Templates for prescription and the community prescription charts are available in System One and in EVOLVE (the electronic patient information system at Ipswich Hospitals Trust) (see appendix 4)
14 Supply of prescription medications
14.1. Within the community setting, all ‘Just in Case Medications’ should be stored in the patient home in a sealed red bag. These are available via community nursing teams.
14.2. Work will continue towards the red Envopak® bag system being used at the point of dispensing from community and hospital pharmacies. Pending this system being agreed community and hospital pharmacies will dispense ‘just in case medication’ according to local policy with a recommendation that there is clear communication from the discharging trust of a ‘just in case medication’ prescription to community teams to allow provision of a red bag. The aim will be for nursing and residential homes to follow the same policy.
15 Storage of Medications
15.1. The patients and their relatives/carers are responsible for the safe storage of their own medication including controlled drugs.
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15.2. To reduce the risk of CDs being unaccountably missing, all schedule 2 and 3 controlled drugs to be stored in sealed Envopak® bag.
15.3. The Envopak®bag must be sealed with numbered seal. A record must be made of the serial number of the security seals used to secure the controlled drugs.
15.4. Spare seals must be kept in the bag at all times to enable staff outside SCH to be able to access the drugs and reseal the bag and record the seal number on the drug chart ie GPs, Marie Curie, Hospice community staff.
15.5. Patients who reside in Nursing Homes must have their drugs stored in the Envopak® bag , which the care home may lock up in accordance with their own policies and procedures.
16 Coordinating ‘Just in Case Medication’ use
16.1. The dying person, those important to them and their carers should be informed of the ‘Just in Case’ medication and the rationale for their use
16.2. Once ‘Just in Case’ medication has been prescribed communicate with other professionals e.g.
a) Adding to EPACCS or other system to share information
b) Inform the Community Nursing service
c) Letter to Hospice and Hospital (see appendix for template)
16.3. At times when deterioration is expected quickly or just prior to an out of hours period such as nights, weekend and Bank Holiday please consider phoning the relevant professionals directly
17 Administration of medications
17.1. When Just in Case subcutaneous medication is administered.
a) The administering doctor/nurse must record the medication and dose given on community prescription chart and update the balance record of any controlled drugs used.
b) The patient’s GP must be informed if there is a significant change in the patient’s condition.
c) The nurse must reassess frequency of review in accordance with patient’s needs
d) The GP or prescriber should:
• Review the patient’s symptoms – the patient may need a change in dose or medicine prescribed
• Prescribe replacement medication if needed via FP10 prescription
• Consider a regular prescription for symptom control if requiring frequent PRNs
• Update the community prescription chart with any new medications or changes in doses/instructions
If medication is required very frequently e.g. 1 hourly for a number of doses, this should be a prompt for urgent further review of their symptom control.
18 Disposal
18.1. A family member should return all medicines to the community pharmacy or dispensary for disposal as soon as possible after a patient dies or medicine is no longer needed.
18.2. When the CDs are no longer required, all medicines are to be returned to the community pharmacy as soon as possible by family/ carers.
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18.3. SCH staff can only transport them if no family/ carer available, and in accordance with the Norfolk and Suffolk Joint Protocol for the Safe and Effective Disposal of both Pharmaceutical and Illicit Controlled Drugs when dealing with the deceased
18.4. ENVOPAKs bags must be removed from the home and returned to the community nursing teams for re-use.
19 Training and Competency/ Increasing Awareness
19.1. New health care staff to which it applies, are required to read the policy on induction. Every member of the health care team has responsibility to check that the intended dose of an opioid medicine is safe for an individual patient.
19.2. When opioid medications are prescribed, dispensed or administered, the health care practitioner concerned should be familiar with the usual starting dose, frequency of administration, standard dosing increments, symptoms of over dose and common side effects.
19.3. Medication should only be prescribed, dispensed and administered by staff that have the necessary knowledge and skills and are confident and competent to carry out this practice.
19.4. Health care staff must identify their own training needs and inform their manager. The requirements for safe management of medicines may change due to changes in legislation or best practice guidance.
19.5. It is therefore essential that all health care staff keep up to date with current practice. Staff should reflect on their medicines – related learning needs when discussing their Personal Development Plans with their manager.
20 Audit
20.1. Audit of this policy needs to be monitored in accordance with the National Quality Markers for end of life care.
20.2. Compliance and effectiveness of this policy should be audited which will include:
a) Reduced need for OOHs referrals for palliative care prescribing
b) Increase use of EPaCCs
c) Reduction in wasted medications
d) Reduction in missing drugs in the home incidents
20.3. Audit of this policy will predominantly occur via community teams. The audit guide in the appendices is for community use.
20.4. Other teams and organisations are encouraged to audit their use of ‘just in case medication’ to optimise prescribing and dispensing practice and to feedback via the regional end of life groups. (for audit proforma see appendix ?)
21 Appendices
21.1. Appendix 1: Processes for set-up of a Just in Case Prescription (anticipatory & active phases)
21.2. Appendix 2: Opioid conversion tool
21.3. Appendix 3: Pre-populated Community Nursing prescription sheets
• Diamorphine
• Hyoscine Butylbromide
• Midazalam
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• Levomepromazine
• Blank Drug administration chart
• Syringe pump chart
21.4. Appendix 4: Ipswich Hospital Evolve Drug administration charts
21.5. Appendix 5: Content of ‘Just in Case’ bag
21.6. Appendix 6: Clinical roles and responsibilities
21.7. Appendix 7: ‘Just in Case’ bag audit proforma
21.8. Appendix 8: Patient information leaflet
21.9. Appendix 9: Generic letter to inform ‘Just in Case’ medications have commenced
21.10. Appendix 10: Ipswich Hospital ward check list
21.11. Appendix 11:‘Just in Case’ one sheet summary
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Appendix 1: Processes for set-up of a Just in Case Prescription
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Appendix 2: Opioid Conversion Chart
Data from BNF 71 August 2016 & PCF 5th Edition
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Appendix 3: Pre-populated Community Nursing Prescription Sheets
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Appendix 4: Ipswich Hospital Evolve Drug administration charts
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Appendix 5: Content of ‘Just in Case’ bag
Contents of a ‘Just in case medication’ pack
a) Information label for just in case box stating
i) Patient name ii) Date of supply iii) Earliest expiry date of medicine contained in the box
b) Regional paperwork for administration of medications
c) Prescribing algorithm for all symptoms
d) Information leaflet for patients/carers
e) Contact details for advice and specialist palliative care
i) GP surgery ii) District nurses iii) Specialist palliative care iv) Other
f) Syringes
g) Diluent
h) Needles
i) Sharps box
j) Medication for pain, nausea/vomiting, terminal restlessness/agitation, excess secretions
k) Medication for any other anticipated symptom or event e.g. seizures, bleeds, airway obstruction
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Appendix 6: Clinical roles and responsibilities
Prescriber (The term prescriber includes doctor, nurse independent prescriber or supplementary prescriber in accordance with individual patient clinical management plan.)
• Identify relevant patient’s ahead of need by reviewing GSF/palliative care registers • Prescribe the appropriate medication on form FP10 or hospital discharge letter • Complete the community prescription chart for them as required/anticipatory medication to be
given by subcutaneous injection (Appendix 1) • Ensure the prescription of medicines and medicines supplied reflect the individual needs of the
patient that include one drug for each indication • Ensure that anticipatory medication is reviewed regularly, at least once a month and after any
known change in circumstances • Explain the purpose of the Just in Case medications to the patient and carers and how and when
the medication will be used • Ensure clear instructions for use of each medication provided • Ensure the patient and carer receive verbal and written information on Just in Case medications
(Appendix 3) • Ensure the patient and carer know who to contact out of hours should any symptoms or
problems occur • Place a note on the patient’s record to indicate that Just in Case medications are held at home
i.e. on Suffolk EPaCCS and/or indicate in yellow folder • Check that a DNCPAR and ACP are in place and arrange for them to be completed if not • Communicate with the patient's GP if the prescriber is not the GP
Role/Responsibility of the GP Anticipatory phase
• Identify patients nearing the end of life who might reasonably be expected to die within the next few weeks or days (GSF Yellow to red). These patients may be identified as a result of a direct or indirect assessment of the patient, as a result of a discussion with other Health Care Professionals involved in the patients care e.g. DN and Community Cancer Nurses or through GSF meetings or through indirect communication with other key professionals involved in the patients care e.g. Hospital and Hospice discharge and outpatient letters.
• Respond promptly (within the same working day) to requests from other key professionals involved in the patients care to prescribe anticipatory drugs. The expectation is that a prescription would be issued
• If a decision not to prescribe is made to liaise with the key professional as to the reason why within the same working day.
• If the decision to prescribe was made by the GP then to inform the District Nursing Service that a prescription was issued.
• Prescribe (issue an FP10) within the Suffolk Wide Guidelines for anticipatory drugs at an appropriate dose and quantity.
• Complete the Suffolk Community Care Nursing Charts, sign the paper copies and leave for the District Nurse to collect in a place agreed locally between the GP surgery and the District Nursing or Hospice at home service.
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• Use the appropriate Drug Administration Charts: a separate A4 chart for each of the "as needed" (prn) drugs and another A3/A4 chart for all the syringe pump drugs, which can all go on the same chart.
• Ensure that appropriate communication between Health professionals occurs to alert them that anticipatory mediation has been prescribed and will be available in the patients home (in a red just in case bag). Such Health professionals should include the Out of Hours Service and Community services. This can be achieved by:
• Enter appropriate read codes in the medical record for "anticipatory end of life drugs" Check that an Advanced Care Plan and DNCPAR form have been completed and are in the patients home in a Yellow Folder.
• Send a Special Patient Note to the Out of Hours Service to alert them that the medication is in the patients home
• Discuss the patient at the next practice Multidisciplinary Palliative Care/GSF meeting Active phase - starting the medication
• The decision to use the medication must be made by an appropriately trained heath care professional.
• GP's should respond to a request from another Health Care Professional to discuss this within an appropriate and prompt time frame, preferably within the hour but always within the same working day.
• Once started then the GP should arrange for the patient to be reviewed within a time frame appropriate to the clinical need (preferably within two working days.
• Ensure that appropriate communication between Health professionals occurs to alert them that syringe driver medication has been initiated and that it is anticipated that the patient may die within the next 7 days. Such Health professionals include the Out of Hours Service and Community services. This is most easily achieved by using the EPaCCS system.
• Enter the appropriate read codes in the clinical records for syringe pump medication started (Check that a DNCPAR and ACP are in place and if not ensure that as a minimum the DNAR is completed as soon as possible
• Discuss the patient at next practice palliative/GSF meeting. Even if the patient has died by then, there may be learning or training needs that can be identified through a significant event analysis.
Community Nurses / Registered Nurse Role and Responsibilities
• Identify relevant patients ahead of need • Liaise with the doctor regarding prescriptions and supply the medications • Ensure adequate supplies of equipment (e.g. needles, syringes, sharps bin etc.) are available in
the home to administer medication • The patient will be referred to the community nursing service when Just in Case medication has
been prescribed. • It is the responsibility of the community nurse/ Marie Curie nurse on the first visit following the
patient’s receipt of the ‘Just in Case’ medication to check the medication. • All medication should be recorded on the community nurses Daily Stock Check of Drugs and the
Drug Administration Record including batch numbers
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• Regularly check the medications to ensure they are in accordance with this policy and record this check in the patient’s notes
• Ensure that they have received necessary training and maintain and update their knowledge and skills in the relevant areas of practice in End of Life care
• On the first visit by the community nurse the medication will be transferred to the Envopak bag provided by the nurses. Sufficient needles for drawing up medication from ampoules, sub cutaneous needles, blunt needles, 2ml syringes and sharps bin to be provided.
• If any controlled drugs are missing this must be reported in the usual way to the Team Lead or out of hours to the Senior Manager on Call and completing an incident form as per the Community Healthcare Teams CD SOP. In the event of controlled drugs the Accountable Officer should be informed.
• The nurse will ensure that patient and carer understand the purpose of the Just in Case Medications; a leaflet about the medication is provided with the Just in Case bag and ensure they know how to contact the community nursing service.
• Once items have been commenced from the initial Just in case medication the community nurse will liaise with the GP for review and a regular prescription for palliative care medicines for symptom control to be considered.
• Ensure that the patient and carer know whom to contact out of hours should any problems occur
• Inform the doctor when medication has been used • Following the patient’s death or if the medication is no longer required the family is responsible
for returning the medication to the community pharmacy for destruction in the CD Evidence bag.
• Ensure that, after an episode of care, the patient’s notes are returned to Suffolk Community Healthcare.
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Appendix 7: ‘Just in Case’ bag audit proforma
Audit proforma:
‘Just in Case’ Medication
PRACTICE/organisation name
Audit of ‘just in case’ boxes
Date when case issued
Auditor’s name (BLOCK CAPITALS)
Patient number/code (please do not use patient name or other identifiable details
Date of Death
Aims of the audit
1. To ascertain the number of ‘JUST-IN-CASE’ bags prescribed
2. To ascertain the wastage of drugs in the ‘JUST-IN-CASE’ bags
3. To discover whether the JUST-IN-CASE boxes improve patient care
Instructions
1. An audit form is to be completed for each patient who has JUST-IN-CASE bag
2. YES/NO questions. Please circle / tick the correct answer to each question
3. Please return questionnaire to your organisation’s Audit Officer/ Team
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Audit Form/ Questionnaire
1. Which drugs were in the JUST-IN-CASE bag to start with’? Drug Number of Tablets or Ampules
Diamorphine Morphine Oxycodone Midazolam Hyoscine butylbromide Glycopyrronium bromide Levomepromazine Metoclopromide
Cyclizine Lorazepam Any others
2. Was the ‘just in case’ bag used? YES NO
3. Were the most appropriate drugs included in the JUST-IN-CASE bag? YES / NO
If you answer this question is NO, please state which drugs should have been included and reason?
Drug name Drug form (tablet / injection / suppository etc.
4. Was any medicine prescribed outside NICE guidance for supportive and palliative care?
YES / NO
5. Did the JUST-IN-CASE box prevent? • An out of hours call to a doctor? YES / NO / UNKNOWN • An admission to hospital? YES/ NO / UNKNOWN • An admission to a hospice? YES / NO / UNKNOWN • A call-out to an out of hours’ pharmacist? YES / NO / UNKNOWN 6. Was there resistance/reluctance to the introduction of the JUST-IN-CASE bag?
YES / NO If there was resistance, was the cause identified, please state?
7. From whom was their resistance/reluctance to have ‘just in case medications’? • By the patient • By the patient’s relatives • By any other person (please identify
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Appendix 8: Patient information leaflet
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Appendix 9: Generic letter to inform ‘Just in Case’ medications have commenced
Template for informing Health Teams that ‘Just in Case Medication’ has been prescribed
Date: (Insert)
Dear (Insert name)
Re: (insert patient details)
This patient is assessed as being at risk of rapid deterioration and requires anticipatory medications for the control of symptoms.
The following medications have been started/ requested on the (insert date)
(CHANGE AS REQUIRED)
Diamorphine (insert dose) SC, max 1 hourly (insert number) ampoules
Other opioid (name, route, dose, max frequency and amount supplied):
Reason for alternative opioid: (Insert)
Hyoscine butylbromide 20mg SC max 2 hourly for secretions, 10 x 20mg/ml 1 ml ampoules
Midazolam
Levomepromazine
Other
Yours sincerely
(Insert name and signature)
This letter is for information and should be sent to:
The appropriate regional hospital (e.g. Ipswich or Bury St Edmunds),
District Nursing Service
Hospice (St Nicholas Hospice or St Elizabeth Hospice as appropriate)
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Appendix 10: Ipswich Hospital ward check list
Ipswich Hospital ‘Just in case medication checklist Recognition of need Decide if anticipatory phase or active phase Initial when
complete Recognition of need Anticipatory phase (at risk of deteriorating rapidly but does not currently need regular PRNs or a syringe driver)
Active phase (currently needing prn for symptom control and high chance of needing a syringe driver in the next few days (If yes consider phone call to GP, DN and/or Hospice as well as written confirmation via discharge summary) If prescribing a ‘just in case syringe driver medication it must be made very clear that it is only to be used after direct review and assessment of need
Doctor has prescribed medication on TTO according to guidance chart (remembering to assess background medication use)
Doctor to prescribe medication on Community prescription charts (available via EVOLVE)
Pharmacy: medication provided Date first medication will expire
Ward to add • Green needles
• Syringes (10ml
• Check diluent available
• Check information leaflet is in the pack
• Check the expiry dates of medication are indicated
• Check patient understands rationale for medication (if has mental capacity)
• Check those important to the patient are aware of use and rationale
Patient informed that just in case medication pack is planned and rationale for its use
If patient not informed due to lack of mental capacity or patient choice Next of kin or appropriate relative informed of ‘just in case medication pack’ aim and use
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Appendix 11:‘Just in Case’ one sheet summary
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Equality Impact Assessment Tool
Any identified a potential discriminatory impact must be identified with a mitigating action plan to address avoidance/reduction of this impact. This tool must be completed and attached to any SCH approved document when submitted to the appropriate committee for consideration and approval.
Name of Policy: SUFFOLK WIDE JOINT GUIDELNE FOR THE PROVISION OF ‘JUST IN CASE’ MEDICATIONS
Equality Impact Assessment Tool Yes/No Comments
1. Does the policy affect one group less or more favourably than another on the basis of:
Race No
Ethnic origins (including gypsies and travellers) No
Nationality No
Gender No
Culture No
Religion or belief No
Sexual orientation including lesbian, gay and bisexual people
No
Age No
Disability - learning disabilities, physical disability, sensory impairment and mental health problems
No
2. Is there any evidence that some groups are affected differently?
No
3. If you have identified potential discrimination, are any exceptions valid, legal and/or justifiable?
N/A
4. Is the impact of the policy/guidance likely to be negative?
No
5. If so can the impact be avoided? N/A
6. What alternatives are there to achieving the policy/guidance without the impact?
N/A
7. Can we reduce the impact by taking different action?
N/A