The hidden issues of anticipatory medications in community palliative care

To the Editor: Most people, because of the “normality” it offers, wish to die at home.1 Additional interconnected factors, including preferences, functional status and caregiving responsibilities, contribute to achieving this desire.2 Key to the inability to stay at home is lack of symptom control, frequently resulting in hospital admission.3

A recent Australian Institute of Health and Welfare report4 shows that about $3 million was paid for medications in the palliative care schedule (about $158 per patient). The report noted a 42% increase in benefits for palliative care schedule items from 2007 to 2012; in particular, a 107% increase for analgesics.

While this trend requires further analysis, what is unknown is how much medication is prescribed as emergency or anticipatory medications. The prescription of such medications ensures availability in anticipation of symptoms that may arise for people receiving care at home.5 Medications are prescribed by a general practitioner or treating specialist, for administration by community nurses in response to assessment of potentially inadequately controlled symptoms. Together with signed orders, medications are generally kept in the patient's home; although, anecdotally, policy and practice relating to storage (including Schedule 4 and 8 medications) vary widely. This availability means nursing staff have the capability to minimise symptoms, often enabling the person to stay at home for longer, and reducing emergency hospital admissions.5 The availability of anticipatory medication is consistent with good palliative care, an exercise in forward planning.6

However, an audit at Melbourne City Mission Palliative Care, a community-based palliative care service, found that anticipatory medications were used in less than 20% of cases. If this is indicative of the general usage of anticipatory medications throughout the country, would there not be a more cost-effective system of drug availability, such as the licensing of nurses to carry a limited equivalent of a doctor's bag? And what of the disposal of the medications not used? To our knowledge, there is no systematised way of returning unused medications to the pharmacy. These issues require further research and costing of an efficient and safe system, with delineated procedures for administration, storage and disposal, for delivering anticipatory medications without disadvantaging those who wish to be cared for and to die at home.