Additional pressures on the healthcare system during the coronavirus (COVID-19) pandemic can challenge the way we approach activities we perform routinely, including the management of medicines. While healthcare professionals are rapidly changing the ways they work, care continues for people living with palliative needs in their home. For some people with palliative needs, remaining at home to die – with the support of a carer and their healthcare team - will be an important option to weigh up.
How can we ensure good medicines management for this vulnerable population?
1. Reassure the public about ongoing medicine supplies
In Australia, the Therapeutic Goods Administration (TGA) is responsible for monitoring issues relating to the supply of medicines during these unprecedented times. At the time of writing, there are no reports of medicine shortages in Australia directly relating to the COVID-19 pandemic. And so, any stockpiling of medicines should be avoided. The Australian COVID-19 Palliative Care Working Group (ACPCWG) is working actively with The Government and its agencies to ensure an understanding of needs of the palliative care sector. The TGA will guide clinicians on medicine shortages as the situation unfolds.
In addition, the Commonwealth’s Continued Dispensing Initiative to permit the emergency supply of Schedule 4 (S4) medicines (unless they are recordable S4 medicines like some benzodiazepines) without prescription for eligible patients. This may be useful when there is an immediate need for that medicine and it is impractical to obtain a prescription. Importantly this process can only be performed ONCE for each medicine in a 12 MONTH PERIOD. Individual State and Territory regulations may apply.
2. Request for medicines to be home delivered
On 11 March 2020, the Australian Government released details of the temporary COVID-19 Home Medicines Service. This provides funding for community pharmacies to deliver Pharmaceutical Benefits Scheme (PBS) and Repatriation Schedule of Pharmaceutical Benefits (RPBS) prescriptions monthly to vulnerable people and those living in isolation.
This is a complimentary service that will keep the vulnerable at home, limit the number of people that need to visit the pharmacy and discourage hoarding of prescription medicines. While it is anticipated that most pharmacies will participate, it is sensible to confirm with participating pharmacies:
- If they require prescriptions to be kept at the pharmacy, in preparation for dispensing; and
- Which days of the week they deliver.
People living in residential aged care homes are also eligible for this Service, unless there is already a contract in place, supporting the delivery of PBS medicines to residents.
Importantly, people eligible for this Service receive one delivery per month, so alternative arrangements will need to be considered for people commencing on new medicines. Medicines that are only available through a public hospital will also rely on alternative arrangements.
3. Anticipate symptom management in the last days of life
Dying at home is an option for many Australians. With increased pressure on the healthcare system during the pandemic, it is expected that many Australians with palliative care needs will continue to spend their last days of life at home.
In the last days of life, the body steadily shuts down, resulting in a loss of the ability to swallow. This results in a shift to the delivery of medicines from the oral to the subcutaneous route, for ongoing management of symptoms. The range of symptoms in this phase can also be anticipated and includes pain, dyspnoea, anxiety, terminal restlessness, nausea and noisy breathing.
Whether you are a pharmacist determining which subcutaneous medicines to have on hand or a prescriber selecting medicines to prescribe, national and state-based organisations have created medicines lists to assist with these decisions; ensuring all parties are on the same page.
Planning is vital and will limit delays in access to subcutaneous medicines. Liaising with the patient’s usual pharmacy prior to prescribing is good prescribing practice, ensuring the preferred medicines are available in a timely way.
4. Coach the carer
While nurses will be involved in setting subcutaneous lines in place, and draw up medication infusions, where they are warranted, it is possible to coach carers – partner, neighbour, son, friend – to administer bolus doses subcutaneously. An innovative National project called Caring@Home has established a range of resources to assist clinicians to train carers in safely administering subcutaneous bolus doses of medicines in the last days of life. Importantly, these resources are applicable Australia-wide for community service providers, offering standardised training materials, fact sheets and tools to help carers to manage breakthrough symptoms at home. Eligible community services providers must be able to offer carers a 24-hour telephone support service.
5. Access prescribing resources
Many clinicians infrequently provide care for people with palliative care needs, so having reliable and evidence-based resources to guide them, within the context of the Australian healthcare system, is vital. Below is a list of free online tools, useful in the management of medicines of people with palliative care needs as well as to support their carers:
Given the multidisciplinary nature of medicines management, it is imperative that we all work together with appropriate resources to support the most vulnerable in the community. CareSearch are committed to keeping people up to date with issues relating to the delivery of palliative care services for community providers during the COVID-19 pandemic.
Paul Tait, Lead Palliative Care Pharmacist, Southern Adelaide Palliative Care Services, SA Health