Four ways to improve medicines management at the end of life

Paul Tait - Lead Palliative Care Pharmacist, Southern Adelaide Palliative Services

Death from acute causes is less common these days, particularly in an economically developed country such as Australia. As such, an expected death resulting from a chronic illness is a reality for many. 

Within the complexity of the Australian healthcare system, there are technical issues making the management of medicines, for the chronically ill, less safe than it could be. For people living with a life limiting illness, the risk of error is increased as they bounce in and out of hospitals, visit multiple prescribers and manage polypharmacy. 

In understanding and responding to the challenges experienced at the end of life, nurses can have a profound impact with people who are dying. To help you to prepare for the challenge of medicines management for the dying, we have provided four helpful tips below.

1. Empower the carer

Carers require complex supports to be effective in their role. In offering reassurance and practical information regarding the changes in function, nurses can empower the carer to contribute in what can be a difficult situation. Understanding pressures such as health literacy and out of pocket expenses will serve the nurse well.

The original, Queensland-specific Caring Safely at Home package is an outstanding example of how carers can be empowered to manage breakthrough symptoms, through the administration of subcutaneous injections.

2. Facilitate integrated multidisciplinary care

Multidisciplinary care is pivotal in the care of people with palliative care needs. Regular changes to their medicines, culminating in the need for subcutaneous medicines once the person loses the ability to swallow, is helped through collaboration with the person’s usual community pharmacy, in anticipation of change.

Initiation of a federally funded MedsCheck or Home Medicines Review (HMR)  when the person is still able to care for most of their needs - requiring only occasional assistance - has a number of benefits, including:

• Sends a clear signal to the person’s usual pharmacy that the person has palliative care needs, prompting them to keep an eye out for the person – and their carer;
• Identifies any medication management concerns for the person (such as swallowing issues or adherence concerns) early so as to be on the front foot; and
• Connecting the person’s carer with the pharmacist, who can be a valuable resource, reinforcing good medicines management practices.

Note HMRs can only be initiated by the GP. MedsChecks and HMRS are only available to people registered with Medicare.

3. Provide the most effective care

Community nursing teams will vary in experience and frequency in managing people with palliative care needs. Having trusted and reliable resources that nurses can rely upon to understand the palliative care journey is important. The CareSearch nurses hub is a great place to start, with links to information about ethical issues, specific population groups, education resources and summaries of research findings to support evidence-based practice.

4. Understand the system

As people approach the terminal phase, they lose the ability to swallow, which has implications on how they can continue to manage symptoms in this critical phase. Get it right and the person has the best chance at remaining comfortable at home. Get it wrong and ambulance callouts and hospital readmissions can be anticipated. 

Accessing medicines through the person’s usual pharmacy is a sensible strategy. Yet community pharmacists can struggle to anticipate which medicines to stock. Appreciating some pharmacies have limited opening hours, planning becomes an essential element to prescribing symptom control. Liaising with the person’s usual pharmacy prior to prescribing is good practice, ensuring the preferred medicines are available in a timely way. Searching for medicines without prior discussions may compromise the timely control of symptoms because the pharmacist was unable to anticipate which medicines to stock.

Together, with the GP, pharmacist and carer, develop a plan to get these medicines into the home early. This may involve writing prescriptions in advance (anticipatory prescribing) and leaving these with the:

• Person’s usual pharmacy; or 
• Carer.

A South Australian initiative uses a Core Medicines List to ensure the subcutaneous medicines held in community pharmacies are also the ones prescribed. There is also a consensus-based list of eight palliative care symptom management medicines suitable for use in the community, and endorsed by The Australian & New Zealand Society of Palliative Medicine. It includes the five medicines in the South Australian list of core medicines. 

Dying in one’s home is good public health practice. Ensuring good symptom control, partnering with the carer, GP and pharmacist, and having access to reliable resources, is important for ensure the process of dying at home happens as well as can be.