Improving Prescribing of Anticipatory Medications for Deteriorating Patients in an Acute Hospital Setting

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Lauren Kaye1, Joseph Clarkson1, Katy Boyce1, Rachel Parry2
1 Department of General Medicine, Wirral University Teaching Hospital (WUTH), 2 Supportive and Palliative Care Team, WUTH
Clinical Quality
CQ - Clinical Effectiveness
End of Life Care

Abstract

Background
Anticipatory medications (AMs) support symptom management in patients nearing end of life. NICE guidance recommends early, individualised prescribing with shared decision-making. At WUTH, AMs are prescribed via a Cerner PowerPlan. A 2023 quality improvement project (QIP) identified delays in prescribing and inconsistent documentation. Interventions included junior doctor and pharmacist teaching, and feedback to the palliative team.

Methods
A retrospective review of adult inpatient deaths during October 2024 at Arrowe Park Hospital was undertaken. Exclusions included sudden and paediatric deaths. Extracted data from electronic records included AM timing, prescribing team and Care in the Last Days of Life (CILDOL) template usage. Results were compared to October 2023 data.

Results
90 patients met inclusion criteria. AMs were prescribed in 98% of patients, up from 96% in 2023. Average time between prescribing and death improved from 6.9 hours to 4.8 days. 76% received AMs within one week of death. Prescription of all four recommended drug classes rose from 84% to 93%. Palliative care referrals occurred in 85% of cases. CILDOL use by the palliative team improved from 60% to 76%, but parent team use remained low (13%). Documentation of side effect discussions improved from 44% to 70%, though over half were brief.

Conclusions
Improvements were seen in timely and comprehensive AM prescribing following targeted education. However, underuse of the CILDOL template by non-specialist teams persists, highlighting the need for ongoing sustained education and system-level prompts. Regular re-audits are planned to embed best practice and support high-quality end-of-life care.

Comments

Really interesting study. Are there plans to try and further improve discussions around side effects of anticipatory medications and documentation of this? Would be interesting to hear of ideas as to how this could be improved further. 

Submitted by ealish.brew_30367 on

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Hi, thanks for your comment! Discussions and documentation around anticipatory medication side effects was a key area that was noted to need significant improvement. In the care in the last days of life (CILDOL) documentation, there is a clear prompt to remind healthcare staff to discuss side effects and then document the discussion. Unfortunately, utilisation of the CILDOL documentation remains low so this will be an area we focus on next, possibly by having pop ups on our electronic system to remind prescribers to fill in the relevant documentation

Hi really interesting thank you. I wondered if you can tell us more about the interventions you used ie what was the education and feedback mechanism? 

Submitted by sineadhenderso… on

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Hi thanks for your comment! We did lecture based teaching sessions on anticipatory medications and CILDOL documentation for F1 + F2 doctors and ward pharmacists. We hope to be able to expand this to other groups of prescribers in the trust. 

Good anticipatory medication prescribing is vital for dignified end-of-life care, and this qip shows clear progress. Consistent adherence across teams is still essential and hopefully that will improve with future reaudits.  
 

Submitted by mehejabeenmurs… on

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