在养老院中对注射类管制药物（ICDs）进行预期性处方：一项关于临终关怀时员工角色、不确定死亡和医院转介的定性观察研究。
Anticipatory prescribing of injectable controlled drugs (ICDs) in care homes: a qualitative observational study of staff role, uncertain dying and hospital transfer at the end-of-life.
机构信息
Department of Social and Policy Sciences, Centre for Death and Society (CDAS), University of Bath, Bath, UK.
出版信息
BMC Geriatr. 2024 Apr 3;24(1):310. doi: 10.1186/s12877-024-04801-z.
BACKGROUND
The anticipatory prescribing of injectable controlled drugs (ICDs) by general practitioners (GPs) to care home residents is common practice and is believed to reduce emergency hospital transfers at the end-of-life. However, evidence about the process of ICD prescribing and how it affects residents' hospital transfer is limited. The study examined how care home nurses and senior carers (senior staff) describe their role in ICDs prescribing and identify that role to affect residents' hospital transfers at the end-of-life.
METHODS
1,440 h of participant observation in five care homes in England between May 2019 and March 2020. Semi-structured interviews with a range of staff. Interviews (n = 25) and fieldnotes (2,761 handwritten A5 pages) were analysed thematically.
RESULTS
Senior staff request GPs to prescribe ICDs ahead of residents' expected death and review prescribed ICDs for as long as residents survive. Senior staff use this mechanism to ascertain the clinical appropriateness of withholding potentially life-extending emergency care (which usually led to hospital transfer) and demonstrate safe care provision to GPs certifying the medical cause of death. This enables senior staff to facilitate a care home death for residents experiencing uncertain dying trajectories.
CONCLUSION
Senior staff use GPs' prescriptions and reviews of ICDs to pre-empt hospital transfers at the end-of-life. Policy should indicate a clear timeframe for ICD review to make hospital transfer avoidance less reliant on trust between senior staff and GPs. The timeframe should match the period before death allowing GPs to certify death without triggering a Coroner's referral.
背景
全科医生（GP）为护理院居民预先开具注射类管制药物（ICD）的做法较为常见，据信此举可减少临终前紧急住院转院的情况。然而，关于 ICD 开具处方的过程及其对居民住院转院的影响的证据有限。本研究调查了护理院护士和高级护理员（高级员工）如何描述他们在 ICD 处方开具中的角色，并确定该角色如何影响居民临终时的住院转院情况。
方法
2019 年 5 月至 2020 年 3 月期间，在英格兰的五家护理院进行了 1440 小时的参与式观察。对各种员工进行了半结构化访谈。对 25 名员工进行了访谈（n=25）并记录了 2761 页手写的 A5 便签（fieldnotes），采用主题分析法进行分析。
结果
高级员工在居民预期死亡前请求 GP 开具 ICD 处方，并在居民存活期间审查处方开具的 ICD。高级员工使用这种机制来确定不提供潜在延长生命的紧急护理（通常会导致住院转院）的临床适当性，并向认证居民死亡医学原因的 GP 证明安全的护理服务。这使高级员工能够为经历不确定死亡轨迹的居民提供护理院死亡服务。
结论
高级员工使用 GP 开具的 ICD 处方和审查来预先阻止临终前的住院转院。政策应明确规定 ICD 审查的时间框架，以减少对高级员工和 GP 之间信任的依赖，避免住院转院。该时间框架应与死亡前的时间段相匹配，以便 GP 在不触发验尸官转介的情况下认证死亡。
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