End of Life Medications as ‘Stock’ in NCHs
Kathy Morris & Jo Hockley
Most people express a wish to end their life in their homes and for many frail older people this means a care home. There are a number of national initiatives and frameworks to support this, for example the Gold Standards Framework for Care Homes Programme, the Ambitions document, One Change to Get it Right and NICE Guidance for Care of dying adults in the last days of life.
This latter document recommends that 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. prn medication for the last days of life. One of the issues for nursing care homes is that these medications are prescribed on a named-patient basis and there can be wastage if these medications are prescribed and then not used. Evidence shows that frail older people in the last days of life, while still requiring some drugs in the last days of life, require less medication than people dying from cancer in mid-life. It is important that such drugs are prescribed but if not used there is wastage.
There is also evidence that residents are sometimes admitted to hospital for the sole reason to access medicines if these medications are not prescribed. This is not only disruptive but inappropriate in many ways.
Stock drugs for Nursing Care Homes
It is legal for nursing care homes to order and keep stock drugs in anticipation for their use during the last days of life. To do so enables residents to receive these drugs without delay, reduce wastage and reduce the number of unnecessary hospital admissions.
We would suggest the following drugs list. Approximate costs are included
|Drug||Approximate cost of one box (2011)|
|Midazolam injection 10mg (CD sch 3)||£8|
|Diazepam rectal solution 5mg (CD sch 4)||£10|
|Metoclopramide injection 10mg||£3|
|Haloperidol injection 5mg||£3|
|Glycopyrronium injection 200mcg||£6|
|Paracetamol suppositories 500mg||£10|
The stock drugs are purchased by each nursing care home individually. These drugs are intended for routine use in the last days of life as well as occasional /unexpected use if prescribed medications for some reason are not in stock.
We have discussed the feasibility of this with our local pharmacist inspector for the Care Quality Commission who is in favour of nursing care homes holding a small stock of end of life care drugs. We are only suggesting this is appropriate for those nursing care homes where training and expertise in managing end of life care and medicines management has been demonstrated.