When a patient with end-stage advanced cancer (or other terminal illness) deteriorates acutely at home with symptoms like pain or breathlessness, it may be their wish to remain at home and be treated palliatively. The delay of waiting to see an out-of-hours doctor, and then to find a chemist open which stocks the drugs can be extremely distressing for both patient and their family.
Two methods of anticipating these situations are the Just in Case box, and a more individualised type of anticipatory prescribing, known here as “Targeted Anticipatory Prescribing”. Both of them aim to optimize end-of-life care for patients at home, and may help to prevent unnecessary admissions to hospital.
Suitable patients may be identified at regular palliative care meetings in the GP practice, or by the specialist palliative care teams. Anticipatory prescribing can be considered as part of Advance Care Planning for the patient.
Just in Case Box
The Just in Case box is an All-Wales scheme which has been approved by the Welsh Assembly Government. A sealed box with standard contents can be prescribed on WP10 and dispensed from participating community pharmacies. It contains injectable drugs for common symptoms such as pain, breathlessness, anxiety or agitation, and is suitable for palliative care patients in the last months of their life. The scheme includes a robust system of audit and control.
The box contains enough drugs to achieve initial symptom control or to last overnight, but additional drugs may be needed if a syringe driver is required, or to cover a weekend. In cases where patients are already on significant doses of opioids, or when the circumstances of their likely deterioration can be anticipated, a more individualised approach to prescribing is appropriate.
Choice of drugs
Diamorphine (or alternative), cyclizine, hyoscine hydrobromide and midazolam are the four commonest drugs used in the last few days of life, and are the drugs recommended in the All-Wales Last Days of Life Care Priorities document (care pathway). The 4 drugs will cover most symptom control needs in palliative care. Haloperidol or levomepromazine are used less frequently for additional management of nausea or agitation.
When to prescribe a Just in Case box
If a patient has a diagnosis of a terminal illness and is considered to have a prognosis of a few months, consider prescribing a Just in Case box. In addition to writing the prescription for the Just in Case Box, you should also consider whether it is appropriate to sign a drug authorisation for the district nurses to administer the drugs on a PRN basis.
Prescribing a Just in Case box
- Identify patient
- Obtain patient's permission
- Offer an Information Leaflet*
- Issue WP10 for full contents of Just in Case box
- The prescribing GP should complete a Notification Form* which should accompany the prescription to the community pharmacy
- Complete a drug authorisation chart (in the box) to authorise nurses to administer drugs, if appropriate
- Refer to the community nursing team for assessment & the introduction of nursing notes into the home
- Inform the out of hours service that a just in case box has been provided
Contents of a Just in Case box
To prescribe a Just in case box, a WP10 for the contents should be produced in the usual way; the exact drugs & quantities must be prescribed. CD prescription requirements apply to the diamorphine & midazolam, including dosage instructions.
“10mg to be administered as directed” is a suitable instruction, whereas just “as directed” or “as required” is not suitable.
- Diamorphine 10mg ampoules x2
- Diamorphine 30mg ampoules x2
- Hyoscine Hydrobromide 400microgm/mL ampoules x3
- Cyclizine 50mg/mL ampoules x3
- Midazolam 10mg/2mL ampoules x4
- Water for Injection 10mL ampoules x2
Example 1You are looking after a patient with bowel cancer. She is receiving palliative chemotherapy but her condition is slowly deteriorating. You feel that her prognosis is likely to be only a few months.
On discussion with her it is clear that she is frightened of being in pain (which she does not currently have), and that quality of life is her priority. She wishes to remain at home “at all costs”, and is realistic about her prognosis.
You should consider prescribing the Just in Case box, and a drug authorisation for PRN administration.
Example 2A patient with NYHA Stage IV heart failure has been told by his cardiologist that there is little more they can do to help his condition. You estimate his prognosis to be less than 6 months, but probably more than a few weeks. He has said that he does not want to go into hospital unless it is absolutely necessary.
During his last admission to hospital he had a chest infection treated with antibiotics, and the patient would not rule out further active treatment if it is appropriate.
You consider that it is quite possible that this patient will deteriorate, and this could happen fairly acutely out-of-hours in circumstances where palliative control of his symptoms at home would be appropriate. You should consider prescribing a Just in Case box, which would reduce delay in accessing injectable drugs for pain or breathlessness.
However you may decide not to write a drug order to allow the district nurses to administer these drugs without further medical assessment of the patient, as it is difficult to anticipate the circumstances in which they may be needed.
Administration of any drug from the box must be recorded on the administration sheet (supplied with the box) as well as in medical records. When a drug has been administered from the box, the patient’s GP should be informed as soon as possible. This will allow a re-assessment of the situation, and supply of further medication to be initiated as appropriate.
When the pack is no longer required, the pharmacy should be informed, and the pack must be returned to the supplying pharmacy by the patient’s family or carers, or a member of the healthcare team if absolutely necessary.
Is it Safe?
The Just in Case box scheme has been approved by WAG and the CMO for Wales. The use of sealed boxes and a close audit trail will prevent widespread abuse, and the small risk of theft of controlled substances, and the cost of the scheme are deemed to be outweighed by an improved quality of end-of-life care.
Targeted Anticipatory Prescribing
If a patient is considered to be in the last few weeks of life, or is being cared for using the Last Days of Life CareDecisions Tool (previously known as the care priorities or care pathway), you should ensure that there is PRN medication available in the home to control pain, breathlessness, vomiting, anxiety/agitation, and death rattle. This will usually be covered by prescribing diamorphine (or alternative), cyclizine, midazolam and hyoscine hydrobromide for PRN SC injection. You should also consider any other predictable complications specific to the patient e.g. seizures or colic.
The tables suggest appropriate quantities to prescribe to cover a 3 day period (Friday night to Monday morning). Larger quantities should be prescribed before Bank Holiday weekends, Easter, Christmas breaks etc.
Example 3A patient with metastatic lung cancer is deteriorating rapidly and he is keen to stay at home. He is taking M.S.T 30mg b.d. and cyclizine 50mg t.d.s. You estimate his prognosis to be less than a few weeks. He is still just managing to take his oral medication at present.
As it is likely that he will need a syringe driver in the near future, and you can anticipate his likely needs, you should consider prescribing drugs needed for a syringe driver as well as PRN drugs for end-of-life care (targeted anticipatory prescribing).
Suitable drugs to prescribe for a syringe driver would be based on his current needs:
- diamorphine 20mg/24hr and
- cyclizine 150mg/24hr
Suitable PRN medication would be:
- diamorphine 5mg SC PRN 4-hourly (based on 24hr dose) - pain or breathlessness
- cyclizine 50mg SC PRN 8-hourly - nausea & vomiting
- midazolam 2.5-5mg SC PRN 4-hourly - anxiety / agitation
- hyoscine hydrobromide SC PRN 0.4mg 4-hourly - death rattle
To determine the quantities to prescribe, look at the tables which follow and refer to the regular daily dose in the left column. Unless there is a Bank Holiday looming, prescribe for 3-days to cover a weekend:
- diamorphine (daily dose=20mg) 10mg ampoules x15
- cyclizine (daily dose=150mg) x15 ampoules (50mg/1mL)
- midazolam (daily dose=nil) x10 ampoules (10mg/2mL)
- hyoscine hydrobromide (daily dose=nil) x20 ampoules (0.4mg/1mL)
These quantities are sufficient to provide for both a syringe driver and PRN doses for 3 days.