Carers’ competency and attitudes to giving subcutaneous medicines

Why teach carers to give subcutaneous medicines to help manage breakthrough symptoms?

Australians consistently say they want to die at home; but few achieve this. Palliative care aims to provide care for patients to live and die in their place of choice. A common reason for transfer to hospital is poor symptom management. Teaching carers to give subcutaneous medicines to help manage breakthrough symptoms safely is one strategy to support care and dying at home.

Educating the carer to help manage breakthrough symptoms using subcutaneous medicines reduces the time the patients may be in distress as the carer can help manage these symptoms quickly without having to wait for the support of a health professional and can potentially decrease unwanted and inappropriate admissions to acute care facilities.

What is the evidence that carers can competently and confidently help manage breakthrough symptoms safely using subcutaneous medicines?

The development of the resources was based on a review of existing Queensland-specific resources with input from nurse and carer focus groups and the caring@home Steering Committee, Education Advisory Group and National Implementation Advisory Committee. There have been several published articles as a result of the implementation of Queensland-specific resources.

Research indicates that with standardised support from health professionals, quality information and resources, carers can confidently, safely and competently give subcutaneous medicines to help manage breakthrough symptoms experienced by the person they are caring for. Carers’ confidence to undertake the task increases after education, especially after the first administration, and carers confidence remains the same regardless of whether the pharmacist, nurse or carer draws up the medicine. In bereavement, carers say they were pleased they had contributed to symptom management and generally feel empowered by the experience.

What role do the caring@home resources have in teaching carers to help manage breakthrough symptoms using subcutaneous medicines?

How do I assess whether carers have the capacity to give subcutaneous medicines?

This is a service-specific decision and is based on the care team’s clinical judgement of the patient and the carer’s capacity to give subcutaneous medicines. Nurses use their clinical judgement consistently in their work and should continue to do so when determining carer suitability to give subcutaneous medicines. It is the service’s responsibility to have a policy in place about initial assessment and determining patient and carer suitability if they wish. The Assessment of carer preparedness to give subcutaneous medicines checklist is available from Appendix 2 of the Example policy and procedures document .  The Training checklist and carer/family post-training competency assessment can be used to guide one-on-one training and to assess carers’ competency to give subcutaneous medicines.

When offered the opportunity, why do carers agree to give subcutaneous medicines to help manage breakthrough symptoms?

Carers want to help manage breakthrough symptoms because they want to help ensure that the person they are caring for remains comfortable and stays at home, if that is their wish. Research tells us that carers who have managed subcutaneous medicines for a person who chooses to die at home say they feel a strong sense of achievement and satisfaction from being able to contribute to symptom relief for the person they are caring for. However, if the carer is not confident to take on the role, the carer needs to be reassured that the patient will still be well cared for by the community service. Evidence shows that carers remain motivated to help with symptom management as they believe their ability to provide subcutaneous medicines adds value to patients’ care.

What happens if the carer gives the last dose of medicine before a person dies? Won’t that lead to extra distress for the carer?

Research indicates that, after education, 90% of carers were unconcerned about the possibility of giving the last injection before a person died and carers place high value on the ability to contribute immediately to the symptom needs of the person they are caring for [1]. Nurses need to provide reassurance as part of the communication about death and dying and be aware of the stressors on carers and provide support.

[1]  Israel, F, Reymond, L, Slade, G, Menadue, S, Charles, MA. Lay caregivers’ perspectives on injecting subcutaneous medications at home. Int J Palliat Nurs. 2008; 14(8): 390 – 395

Why does caring@home suggest flushing the subcutaneous cannula with 0.9% sodium chloride and not water for injection?

Water for injection is hypotonic, increasing the risk of reactions and has been linked with pain.¹ Alternatively, 0.9% sodium chloride (Normal Saline) is isotonic and matches body tissue salt levels. It is recommended that 0.9% sodium chloride be used except when flushing after Cyclizine or Diamorphine where crystallization can occur.

How can you support your patients and their families and carers?

Everyone in your patient’s health care team has an important role.

Nurses will use the caring@home resources to teach carers and family how to provide practical care and give subcutaneous medicines. They’ll also give them a 24-hour phone number to ring if they’re worried or need advice.

Doctors and nurse practitioners will prescribe the medicines used to treat breakthrough symptoms.

Pharmacists will stock and dispense any prescribed medicines and make sure carers and family understand what they are and answer questions they have.