Palliative Medicine, Clatterbridge Cancer Centre NHS Foundation Trust, Bebington, Wirral, UK
University of Liverpool, Liverpool Head and Neck Centre, Liverpool, UK.
BMJ Support Palliat Care. 2024 Jan 8;13(e3):e1373-e1378. doi: 10.1136/bmjspcare-2021-003259.
The anticipatory prescribing of pro re nata medications and continuous subcutaneous infusion (CSCI) medication is essential for the timely management of symptomatic patients at the end of life. There is no evidence to support the safety or appropriateness of anticipatory CSCIs. In 2013, in response to safety concerns about end of life prescribing in the community, we designed an educational intervention to improve prescribing practices among non-specialist prescribers in this area.
We performed a safety-focussed retrospective cohort analysis of end of life community prescriptions of anticipatory CSCIs over a 12-month period, 5 years after creating clinical guidelines and embedding a multiprofessional rolling education programme. Medications prescribed and administered for symptom control at the end of life are compared between specialist and non-specialist prescribers in terms of their adherence to best practice guidance.
Medications prescribed were not universally administered and more commonly not administered without specialist input. Prescriptions of higher doses of opioids and benzodiazepines beyond those recommended by guidance were significantly greater within the cohort of patients receiving specialist oversight. The prescription of a dose range did not result in excessive dose escalation. For patients not receiving specialist palliative care, median morphine and midazolam doses did not escalate at all once a CSCI was commenced. All midazolam administrations were safe.
The practice of anticipatory CSCI prescribing and administration can be safe in the community non-specialist setting when supported by clinical guidelines, specialist advice and ongoing multiprofessional education.
在生命末期，对患者进行症状管理时，需要提前开具 pro re nata 药物和皮下持续输注（CSCI）药物。目前尚无证据支持提前开具 CSCI 的安全性或适当性。2013 年，为回应社区临终处方方面的安全问题，我们设计了一项教育干预措施，以改善该领域非专科处方者的处方实践。
我们对 12 个月内社区临终患者提前开具 CSCI 的情况进行了安全性为重点的回顾性队列分析，这是在制定临床指南并嵌入多专业滚动教育计划 5 年后进行的。我们比较了专科和非专科处方者开具的用于缓解症状的药物，看其是否符合最佳实践指南。
并非所有开的药物都得到了普遍使用，而且在没有专科医生参与的情况下，药物使用更为常见。在接受专科监督的患者队列中，开具的阿片类药物和苯二氮䓬类药物的剂量明显高于指南推荐的剂量，且超出了推荐剂量。开处方时给出剂量范围并不一定会导致剂量过度增加。对于未接受专科姑息治疗的患者，一旦开始皮下持续输注，吗啡和咪达唑仑的中位数剂量根本没有增加。所有咪达唑仑的给药都是安全的。
在有临床指南、专科医生建议和持续的多专业教育支持的情况下，社区非专科环境中提前开具 CSCI 并进行管理的做法是安全的。
