Anticipatory Prescribing of Injectable Controlled Drugs (ICDs) in Care Homes: a qualitative observational study of Staff Role, Uncertain Dying and Hospital Transfer at the End-of-Life

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Abstract

Background: The anticipatory prescribing of injectable controlled drugs (ICDs) by general practitioners (GPs) to care home residents is common practice and is believed to reduce emergency hospital transfers at the end-of-life. However, evidence about the process of ICD prescribing and how it affects residents’ hospital transfer is limited. The study examined how care home nurses and senior carers (senior staff) describe their role in ICDs prescribing and identify that role to affect residents’ hospital transfers at the end-of-life. Methods: 1,440 h of participant observation in five care homes in England between May 2019 and March 2020. Semi-structured interviews with a range of staff. Interviews (n = 25) and fieldnotes (2,761 handwritten A5 pages) were analysed thematically. Results: Senior staff request GPs to prescribe ICDs ahead of residents’ expected death and review prescribed ICDs for as long as residents survive. Senior staff use this mechanism to ascertain the clinical appropriateness of withholding potentially life-extending emergency care (which usually led to hospital transfer) and demonstrate safe care provision to GPs certifying the medical cause of death. This enables senior staff to facilitate a care home death for residents experiencing uncertain dying trajectories. Conclusion: Senior staff use GPs’ prescriptions and reviews of ICDs to pre-empt hospital transfers at the end-of-life. Policy should indicate a clear timeframe for ICD review to make hospital transfer avoidance less reliant on trust between senior staff and GPs. The timeframe should match the period before death allowing GPs to certify death without triggering a Coroner’s referral.

Original languageEnglish
Article number310
JournalBMC Geriatrics
Volume24
Issue number1
Early online date3 Apr 2024
DOIs
Publication statusPublished - 3 Apr 2024

Data Availability Statement

The anonymised interview data used in this study may be requested by researchers through contacting the lead author (DT). Given the sensitive subject nature of the anonymised qualitative data, they may be made available to researchers with evidence of a study protocol and Research Ethics Committee approval, and on completion of a data use and sharing agreement.

Keywords

  • Anticipatory prescribing
  • Care home palliative care
  • End-of-life care
  • Nursing home
  • Older adults

ASJC Scopus subject areas

  • Geriatrics and Gerontology

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