Abstract
Introduction
End-of-life (EOL) care in care homes includes patients experiencing "ordinary dying" from dementia or frailty, alongside those with chronic diseases and cancer. Recognizing non-specific decline is complex. The One Weston Care Home Hub (CHH) implements comprehensive EOL care, achieving 95% of deaths in the preferred place and prioritising a "good death". Whilst "Just in Case" (JIC) injectable medications are commonly prescribed, a broader understanding of prescribing patterns is useful for learning about medicines waste and recognition of dying. This study investigates the prevalence of common prescriptions and explores the need to re-evaluate anticipatory medications for care home residents.
Method
A qualitative audit evaluated EOL care prescribing practices in 100 care home deaths by examining medication management in patient notes. Data were collected retrospectively on parameters including the completion of palliative drug charts, issuing JIC medications, and the timeline from prescribing JIC medications to death. Information on medications administered within the last two weeks of life and the cause of death was also recorded.
Results
34% received no additional medications. Antibiotics were the most commonly issued medications; 31% patients received them, half in liquid form. Other prescriptions included oral or topical analgesia (21%), laxatives (9%), benzodiazepines (8%), and oral steroids (5%). Liquid preparations comprised half of the issued medications. 74% of patients had JIC medications issued a median of 23 days before death (range: 1-1244 days).
Discussion
The use of antibiotics in this cohort is complex: are they prescribed for successful treatment, or could braver decisions be made not to prescribe when recovery chances are limited? Injectable JIC medications are a timely proxy for recognizing the terminal phase, but 26% of patients who died did not have these in place. Further study is required to determine if they were indeed not needed and how many of those prescribed were used.
Comments
Just in Case medication
Its so tricky anticipating who might benefit from JIC meds. In my experience, I often put JIC meds in place for care home residents who never need them, which is undoubtedly a huge waste. I have also had distressing events, where a resident unexpectedly deteriorated, and we are all scrabbling about back and forth to the practice/pharmacy, wishing we had sorted things earlier.
Wouldn't it be great if care homes could have a generic JIC cupboard, so that drugs could be prescribed and sourced at short notice for any of the residents. We did manage to do this in a limited way at the height of Covid, but the consensus seems to be that inspecting bodies will not permit drugs in the building that are not labelled for a named individual.
Perhaps one day......