In its 'Dying Well' report published in September last year, the Grattan Institute said 14% of Australians die in their own home. The option of care at home is often well-received by patients and carers alike. Enablers for people to remain at home include support from their general practitioner (GP) as well as access to good symptom control.

Given the small proportion of people who require support at home in the last days of life and the infrequency of managing this patient group, there are some simple tips for GPs to consider with regards to prescribing medicines. These five tips help the GP to anticipate the barriers to timely access to good symptom control and possibly avoid an unnecessary hospitalisation for an issue that could have been effectively managed in the community.


 

1. Anticipate the symptoms to be managed
   In the last days of life, a small range of symptoms can present suddenly or be exacerbated (figure 1). Importantly, these can be anticipated.
   
   Figure 1: Common symptoms expected in the last days of life
    
2. Consider which combination of medicines you are likely to prescribe
   As dysphagia is common in the last days of life, the administration of medicines is often restricted to either oral liquids or subcutaneous injections. While Australian guidelines contain broad recommendations for the pharmacological management of these anticipated symptoms, most GPs will favour some options over others. A couple of approaches to establishing a defined list include:

• Until the chemist opens - palliation from the doctor's bag
• Core palliative medicines: Meeting the needs of non-complex community patients

3. Document each patient’s usual pharmacy
   As we grow older and develop more comorbidity, there is good evidence to show that we access medicines through the same community pharmacy.This may be for practical reasons, trust, or simple economics. Either way, having the particulars of this pharmacy in mind may help fast-track access to medicines where unexpected deterioration occurs by leveraging a relationship that already exists.
    
4. Involve the community pharmacist ahead of time
   Accessing medicines through the patient’s usual pharmacy is a sensible strategy, to access these medicines within a timely manner. Yet with various GPs, each with their own personal preferences, prescribing different combinations of medicines and formulations, community pharmacists can struggle to reliably anticipate which medicines to stock.
   It may be expensive and runs the risk of stock going out of date if pharmacies choose to carry all options. Alternatively, if pharmacies choose to order stock in as it is prescribed, there can be delays in accessing the stock – compromising timely access to good symptom control.
   Appreciating some pharmacies have limited opening hours, planning becomes an essential element to prescribing symptom control. Liaising with the patient’s usual pharmacy prior to prescribing is good GP practice, ensuring the preferred medicines are available in a timely way.
    
5. Identify a good quality dosing resource and get familiar with its layout
   Appropriate use of medicines requires an understanding of routes of administration, appropriate doses, knowledge of the duration of effect and of adverse effects. Doses should be individualised and based on reputable resources. Some options include:

• Palliative Care Therapeutic Guidelines
• palliAGED smartphone app
• Guide to the Pharmacological Management of End of Life (Terminal) Symptoms in Residential Aged Care Residents: A Resource for General Practitioners (259kb pdf)

Standard Pharmaceutical Benefits Scheme (PBS) rules apply to each of these medicines.

Anticipating the range of medicines you are likely to prescribe and discussing this with the community pharmacist ensures that the particular medicines that are prescribed are also the ones that are available. While there are many challenges that affect the care of palliative patients in their home environment, access to medicines for the relief of frequently anticipated symptoms should not be one of them.






Paul Tait is the Lead Palliative Care Pharmacist with Southern Adelaide Palliative Services at the Repatriation General Hospital.