Implementing the recommendation on medication management and symptom control Mike Grocott Professor of Anaesthesia and Critical Care Medicine University of Southampton Consultant in Critical Care Medicine University Hospital NHS Foundation Trust, Southampton @mike_grocott NICE NG31 Guideline Development Group Member
Declarations This work was undertaken in part as a result of my role on the Guideline Development Group (GDG) for the Care of the Dying Adult which received funding from the National Institute for Health and Care Excellence. The views expressed in this presentation are those of the author and not necessarily those of the Institute or the GDG. 2
Disclosures Elected council member, Royal College of Anaesthetists Elected board member, Faculty of Intensive Care Medicine Director, NIAA Health Services Research Centre NIHR CRN National Specialty Lead for Anaesthesia, Perioperative Medicine and Pain. Critical Care Physician Academic Likely to die (based on family history) 3
16 th October 1846 - Massachusetts General Hospital
UHS: ahead of the game?
Aims Delivering effective medication review at the end of life Symptom control in the last day(s) of life Implementing the clinical guideline recommendations 8
Drug management & symptom control Background and context Process NICE GDGs Recommendations and implementation Hydration Pharmacological interventions Anticipatory prescribing 9
The most important themes. Control & choice Benefit & harm Evaluate, review & document in care-plan 10
Background: Liverpool Care Pathway
Background: Liverpool Care Pathway
Background: Liverpool Care Pathway Recognising that a person was dying was not always supported by an experienced clinician and not reliably reviewed, even if the person may have had potential to improve. The dying person may have been unduly sedated as a result of injudiciously prescribed symptom control medicines. The perception that hydration and some essential medicines may have been withheld or withdrawn, resulting in a negative effect on the dying person. 13
Background: More care, less paathway Uncertain terminology No evidence Linked with poor documentation Diagnosis of dying uncertain Inappropriate decision making Unilateral decisions No consent Protocol driven prescription Nutrition and hydration Other prescriptions Lack of compassion
Background: One change to get it right Compassionate care Based on, and tailored to, the needs of dying patients, their families and those important to them Regular effective communication Assessment, reassessment and response to change Senior responsible leader Delivered by practitioners with skills, knowledge and experience
Background: One change to get it right Compassionate care Based on, and tailored to, the needs of dying patients, their families and those important to them Regular effective communication Assessment, reassessment and response to change Senior responsible leader Delivered by practitioners with skills, knowledge and experience
Background: One change to get it right Compassionate care Based on, and tailored to, the needs of dying patients, their families and those important to them Compassion is the response to the suffering of others that motivates a desire to help Regular effective communication Assessment, reassessment and response to change Senior responsible leader Delivered by practitioners with skills, knowledge and experience
Background: One change to get it right
Background: NICE NG31 Remit received January 2014 NICE Guidance Guideline Development Group Scoping July 2014 Scope Consultation August 2014 12 GDG meetings Consultation July-September 2015 Response to consultation Publication 16 th December 2015
NICE Guideline process Guideline development group (GDG) NICE civil service Technical staff Systematic reviews Health economics Drafting, revising and production Care of the dying adult (CODA) = 72 recommendations
Care of dying adults (NG31) Recognising when a person may be in the last days of life Communication and shared decision making Maintaining hydration Pharmacological interventions Anticipatory prescribing
Care of dying adults (NG31) Maintaining hydration (10) Pharmacological interventions (34) General (9) Pain (5) Breathlessness (3) Nausea and vomiting (5) Anxiety, delirium, agitation (6) Noisy respiratory secretions (6) Anticipatory prescribing (6)
Half full glass
CODA: maintaining hydration Patient wishes drive care: Oral hydration is simple and desirable Discuss the risk and benefits of continuing to drink Support the dying person to drink if they wish to Mouth and lip (+ teeth and denture) care +/- sips Document evaluation, communication & conclusion
CODA: clinically assisted hydration Review hydration status & need for CAH daily Discuss benefits & harms: CAH may improve or worsen symptoms CAH effect on duration of life uncertain Consider a therapeutic trial of CAH Review daily (benefit/harm) recognise changes with time Document evaluation, communication & conclusion
CODA: clinically assisted hydration These recommendations could lead to some costs associated with providing equipment and support for the dying person.. This should help more people to stay at home and avoid going into hospital. Cost of equipment for setting up subcutaneous assisted hydration in the community as around 9, while around 10 minutes of staff time is required. The average cost for an additional hospital bed day is 222 per day (national tariff 2015-16).
CODA: pharmacological interventions Consider non-pharmacological interventions Treat reversible causes (e.g. urinary retention) Review medications and focus on symptoms: Stop long-term medicines not providing symptom relief Stop long-term medicine that may cause harm Start medicines for symptom control Regularly reassess treatment plans ( daily) 27
CODA: pharmacological interventions Evaluate and discuss benefits and harms Consider best route (avoid IM) - PO if possible, SC, IV if not Start with lowest effective dose, titrate as clinically indicated Consider syringe pump if >2-3 as required doses in 24 hours Regularly reassess (at least daily) symptoms and side effects Seek specialist palliative care advice if: Symptoms do not improve Undesirable side effects 28
CODA: drugs 4 specific symptoms Clinical evidence (GRADE) Economic evidence Evidence statements Recommendations and links to evidence
CODA: drugs 4 pain Clinical evidence = 1 study GRADE = very low x 4 Economic evidence = none
CODA: drugs 4 pain
CODA: drugs 4 pain
CODA: drugs 4 pain
CODA: drugs 4 pain Non-opiod Oral: Paracetamol or Ibruprofen Rectal: Diclofenac or Paracetamol IV: Paracetamol Opiod Oral/sub-cutaneous or iv Morphine
CODA: drugs 4 breathlessness Clinical evidence = 3 studies GRADE: moderate x 1, low 13, very low x 12 Economic evidence = none
CODA: drugs 4 breathlessness Clinical evidence = 3 studies GRADE: moderate x 1, low 13, very low x 12 Economic evidence = none
CODA: drugs 4 breathlessness First-line Oral/sub-cutaneous/IV Morphine Second-line Oral/sub-lingual/buccal/rectal/IV Benzodiazepine (Diazepam, Lorazepam, Midazolam, Clonazepam)
CODA: drugs 4 breathlessness 38
CODA: drugs 4 breathlessness 39
CODA: drugs 4 breathlessness First-line Oral/sub-cutaneous/IV Morphine Second-line Oral/sub-lingual/buccal/rectal/IV Benzodiazepine (Diazepam, Lorazepam, Midazolam, Clonazepam) Only offer oxygen therapy to people known or clinically suspected to have hypoxaemia
CODA: drugs 4 nausea & vomiting First-line: Oral Cyclizine OR Domperidone OR Haloperidol OR Metaclopramide OR Prochloperazine Buccal/sub-cutaneous/IV Prochlorperazine OR Cyclizine OR Haloperidol OR Metaclopramide Second line: Oral/sub-cuteneous/IV Levomepromazine
CODA: drugs 4 anxiety +/- agitation First-line: Oral/sub-lingual Diazepam OR Clonzepam OR Lorazepam Sub-cutaneous/IV Clonazepam OR Midazolam
CODA: drugs 4 delerium First line: Oral Haloperidol OR Olanzapine OR Resperidone Orodispersible Olanzapine OR Resperidone Sub-cutaneous/IV Haloperidol OR Levomepromazine
CODA: drugs 4 noisy respiratory secretions First line: Sub-cutaneous Hyoscine hydrobromide OR Glycopyrronium bromide Transdermal Hyoscine hydrobromide Sub-lingual Atropine Sub-cutaneous/IV Hyoscine butylbromide SCCI Hyoscine hydrobromide OR Glycopyrronium OR Hyoscine butylbromide
CODA: anticipatory prescribing Early individualised (and anticipatory) symptom control Assess: Needs (present and anticipated) Possible solutions (indications and doses) Benefits and harms (of action and inaction) Place of care and speed of access Communication = shared decision making Prescribe in anticipation - administer as required Review/monitor (at least daily) and adjust
Recommendation for Research 2. Agitation and delirium What is the best way to control delirium, with or without agitation, in the dying person, without causing undue sedation and without shortening life? 3. Noisy respiratory secretions In people considered to be in the last few hours and days of life, are antisecretory anti-muscarinic drugs (used alongside nursing interventions, such as repositioning and oropharyngeal suction) better at reducing noisy respiratory secretions and patient, family and carer distress without causing unwanted side effects, than nursing interventions alone? 4. Anticipatory prescribing What is the clinical and cost effectiveness of anticipatory prescribing for patients dying in their usual place of residence, on patient and carer reported symptoms at end of life?
Drug management & symptom control Control & choice Benefit & harm Evaluate, review & document in care-plan Hydration (and CAH) Pharmacological interventions Anticipatory prescribing
Questions? @mike_grocott mike.grocott@soton.ac.uk