Post of the Month: November 2017
Written by: Dr Hannah Rose, Core Medical Trainee
Rationalising medications at the End of Life… to cross off or not to cross off?
One of the things I find satisfying about Palliative Medicine is crossing off medications and reducing a patient’s tablet burden. Another moment of contentment comes when I’m able to condense several paper drug charts (we’re still a way off electronic prescribing at my trust) into just one which is filled with entirely symptom-based medication. I find myself regularly encouraging colleagues to think “is this making a difference to the patient’s quality of life now? If not, stop it!”
However, this process is often far from simple. Polypharmacy in patients reaching the end of life is extremely common. Deciphering which medications are likely to make a difference to their symptoms at the end of life is not black and white. In the acute hospital setting, as with many complex decisions, the task of rationalising medications is often left to some of the most junior members of the medical team.
I carried out a survey of junior doctors at my hospital regarding their confidence and experience in prescribing at the end of life. This revealed a need for further training and guidance to improve safety in practice: 50% said they lacked confidence in prescribing at the end of life and 100% felt that they would find further guidance and teaching on this topic useful. Indeed, a particular area of concern was the rationalisation of regular medications: Junior doctors were unsure as to which medications could be stopped safely and which needed more careful and specific management.
With this in mind, I joined forces with our specialist end of life nurses and the palliative care team to carry out a patient safety quality improvement project. We produced a guidance document focusing on the following key areas:
Paracetamol and NSAIDs
The guidance document was placed inside pre-existing end of life resource folders on each ward and information was circulated via email signposting junior doctors throughout the trust to this information. The document was designed to be used alongside the existing “Personalised Care Framework for the End of Life” guidance and documentation.
Doctors were asked to indicate that they had used the guidance to rationalise medications by placing a butterfly sticker on the front of drug charts and by completing a feedback form. This enabled assessment of when the guidance was used and enabled pharmacists, nurses and other members of the multi-disciplinary team to identify patients whose medications had been reviewed.
The guidance document was well received by junior doctors and initial feedback was that it was used regularly when reviewing medications for patients at the end of life. We now signpost to the information from our “Personalised Care Framework for the End of Life” documentation.
The project highlighted a need for education in some of the more complex areas of end of life prescribing and as a result teaching sessions are being planned for junior doctors at the trust. The project has also prompted the need for an audit of end of life prescribing both in terms of rationalisation of medications and also prescribing anticipatory medications which we hope to pursue in the near future.
I hope that this guidance will mean that we all take some time to consider the potential outcomes, before we enjoy the rather therapeutic act of putting a line through the drug chart!