Supplementary prescribing differs from independent prescribing in that the treatment regime is agreed with a medical clinician. (Dhillon and Sodha, 2009). An assessment of the patient’s condition is carried out by the doctor who then provides guidance for prescribing decisions in a clinical management plan (CMP). The CMP provides a supportive prescribing partnership between practitioners, both of whom have accountability to ensure that the patient is prescribed the medications required to treat their condition. Clinical Management Plans (CMPs) are beneficial as they allow timely access to treatment for specific patients. Involving the patient in discussions about the CMP ensures its validity as the patient must have the mental capacity to consent to the plan under current legislation. If at any time either of the parties need to withdraw from the CMP, then it must stop, and consideration be given to an alternative.
The use of supplementary prescribing is limited within acute medicine for the older person as the individual’s mental capacity might be diminished during the acute phases of illness. However, CMPs can be useful for the management of long term health conditions. This case study will discuss a CMP that was used for a 75-year-old lady who will be referred to as Chris to maintain anonymity. Chris was an inpatient on a care of the elderly ward and suffered from end stage heart failure. She was dyspnoeic, requiring continuous high flow oxygen since admission. Her past medical history included hypertension and cataracts. Several recent hospital admissions due to dyspnoea indicated that Chris was at the end stage of her heart failure as her symptoms were becoming unresponsive to treatment. She also had these symptoms at rest which Nicolson (2007) suggests is a sign of poor prognosis. Chris also displayed symptoms of anxiety which were due to her deteriorating health.
Chris had a good understanding of her illness and asked for plans to be in place to manage her symptoms when they occurred. Chris was mainly worried about “struggling to breathe” and pain towards the end of her life. Chris had reached what she called “the end of the road” and she agreed to palliative care.
The role of nurses in providing palliative care to heart failure patients can be challenging. Ivany and White (2013) suggest that the palliative needs of patients with non-malignant chronic disease are poorly understood. Additionally, death from heart failure does not follow a predictable pattern (Nicholson, 2007). Lewis and Stevens (2005) further suggest that most physicians who manage heart failure are committed to preserving life and focus on aggressive therapies rather than the patient’s quality of life. Ethical consideration needs to be given as to when to withdraw treatment, whilst this can be an admission of failure for the clinician it is imperative to ensure that the patient has autonomy over decisions about their care towards the end of life.
Chris felt reassured that the CMP would allow her to have timely access to adequate pain relief and symptom control medications throughout her journey. The CMP was agreed and drawn up with all three parties. A discussion was held with Chris and her daughter to ensure that all agreed with the plan. We explained that administration of the medications would be through a continuous subcutaneous infusion (CSCI) and if we felt that the doses needed titrating that the supplementary prescriber would do this using guidance from the CMP. Chris was relieved to know her symptoms would be managed; however, her daughter was naturally upset as the CSCI indicated that her mother was nearing the end of life. Whilst discussing anticipatory medications may involve difficult discussions, it is important to remember that these medications will counteract any distressing symptoms towards the end of life. The CMP (appendix one) included four anticipatory medications that are commonly used to manage symptoms in palliative care. The commonest symptoms being pain, breathlessness, nausea and vomiting, respiratory secretions and agitation (Westlake et al, 2002).
The first medication was analgesia to control pain. When oral preparations are not appropriate because the patient is nearing the end of their life and is unable to manage oral drugs, a subcutaneous opioid is usually the first-choice analgesic. (Hawkins A, Cited in Woodfield et al 2016). Diamorphine hydrochloride is the preferred choice of opioid (NICE, 2012), due to its solubility as it can be given in higher concentrations. The BNF 74 (2018) also suggests that it causes less nausea than morphine. However, due to a national shortage of diamorphine most NHS Trusts have changed over to morphine sulphate. As well as being an effective analgesic morphine can also relieve dyspnoea due to its vasodilatory properties. It reduces pulmonary congestion by decreasing what is termed as afterload. (Westlake et al, 2002). It also affects the central nervous system to slow breathing and act as an anxiolytic. (Woodfield et al, 2016). This helps the patients breathing by reducing experienced or potential anxiety. It is important to be aware that morphine should be avoided or used in reduced doses for patients with renal impairment (BNF 74, 2018). Chris estimated Glomerular Filtration Rate (eGFR) was 45 but had it been less than 30 the prescriber would have considered using an alternative such as oxycodone. Current literature supports local guidelines in recommending oxycodone as a suitable alternative for patients with renal impairment. (NEEG, 2016). The CMP listed morphine sulphate to manage Chris pain. The patient had never taken oral opioids, therefore a low dose of 2.5mgs was administered to monitor its effectiveness along with any adverse effects. Chris found it to be effective in managing both her pain and her breathlessness and she felt what she described as “some relief”’ from her symptoms. For this reason, Chris agreed to start a CSCI which could be titrated to ensure that her symptoms were managed. As Chris received two further doses of 2.5mgs of morphine sulphate overnight, she was commenced on a twenty-four-hour CSCI containing 10mgs morphine sulphate the following day.
Nausea and vomiting are a common side effect of opioid analgesics which activate the chemoreceptor trigger zones in the brain. (Westlake et al, 2002). Levomepromazine is thought to act predominantly by blocking dopamine type 2 (D2) receptors in the brain (NICE, 2015). Initially used as a first-generation antipsychotic drug it was reported by many to have multi-modal actions. Authors such as Brayfield (2013) claim that levomepromazine has strong analgesic, hypnotic and antiemetic properties. However, a more recent review of the literature by Dietz et al (2013) concludes that aside from two small studies one by Oliver et al (1985) and one by Rogers (1989) there are no recent published articles on the use of levomepromazine as an effective analgesic in palliative care. Local guidelines (NEEG, 2016)do however recommend it as a first line anti-emetic. With no randomised controlled trials to support its use the evidence base supporting levomepromazine remains weak. (Dickman and Schneider, 2016). Levomepromazines popularity is based upon its widely reported effectiveness that is described by palliative care specialists in clinical practice. (Dietz et al, 2013). If nausea and vomiting become persistent a practitioner may consider prescribing higher doses to relieve symptoms. Risk versus benefit would need to be considered however, as sedation is a common side effect of levomepromazine at higher doses. Whilst this may be of benefit to patients with terminal agitation it was not a side effect that we felt the patient would benefit from. Whilst Chris did not experience any vomiting she did report feeling “queasy.” Levomepromazine was therefore used at a low dose to treat her nausea. This was added to the CSCI at 12.5mgs. The recommended maximum dose is 25 mgs, this allowed for some titration however Chris found 12.5mgs to be effective.
Increased respiratory secretions caused by pulmonary oedema can be a symptom that requires treatment in end stage heart failure. A past review of the literature found no evidence that any of the commonly used agents (hyoscine butylbromide, hyoscine hydrobromide or glycopyrronium bromide) were more effective than the others (Wee and Hillier, 2008). However more recent evidence warns that hyoscine butylbromide should be used with caution in patients with underlying cardiac disease as it can cause serious adverse effects such as tachycardia, hypotension and anaphylaxis (BNF 74, 2018). Hyoscine hydrobromide is also advised against as it crosses the blood-brain barrier and causes agitation. (Woodfield et al, 2016). Glycopyrronium bromide is favoured as it provides a greater cardiovascular stability, a degree of amnesia, and additionally reduces emesis. (BNF 74, 2018). It acts by blocking muscarinic receptors, thereby inhibiting cholinergic transmission which regulates bronchial secretions. (Wee and Hillier, 2008). Glycopyrronium does not relieve chest secretions that are already present, it is imperative that treatment is started as soon as secretions become apparent (Dickman and Schneider, 2016). Chris had started to experience some secretions, so glycopyrronium was added to the CSCI at 600mcg over twenty-four hours.
The fourth anticipatory medication listed on the CMP was midazolam. A short acting benzodiazepine which enhances the action of GABA neurotransmitters within the brain causing a calming effect, it is used for agitation and restlessness in palliative care. (De Graeff and Dean, 2007). It was listed on the CMP at a dose of 2.5-5mgs for Chris in case of restlessness and agitation. The patient did not require any doses, so it was not used. This may have been because the morphine sulphate and levomepromazine used in the CSCI also helped to calm Chris and reduce any potential anxiety. Consideration was given to the compatibility of drugs that were added to the CSCI. Faull and Blakney (2015) suggest that interactions can cause a reduction in stability or changes in solubility resulting in precipitation or crystallisation. All the drugs listed on the CMP were known to be compatible by both prescribers who had experience of palliative care medications and knowledge of National (NICE, 2012) guidelines as well as the North East Essex palliative care guidelines (NEEG,2016).
The CSCI was started the day after the CMP was written and it was reviewed daily by the supplementary prescriber. As part of the review consideration was given to the patient’s symptoms, and discussions were held with the patient, the nursing staff and the patient’s family. The supplementary prescriber reviewed the CMP with the independent prescriber every other day. On the third day Chris condition started to deteriorate and she required three additional doses of morphine sulphate 2.5mgs, the dose was therefore increased following local guidelines which recommend an increase of 30-50% of the previous prn doses. The morphine sulphate in the CSCI was increased to 12.5mgs over twenty-four hours and was effective at this rate. Two days later Chris passed away peacefully. Although her CSCI was prescribed under a clinical management plan on the day she died she became drowsy and was unable to converse with the supplementary prescriber during her final hours. At this point Chris lacked the mental capacity to consent to the continuation of the CSCI so it was continued using a best interest decision under The Mental Capacity Act (2005) in consultation with her family and the independent prescriber.
In summary, supplementary prescribing is not commonly used in the acute hospital setting however it was useful for Chris as it provided her with timely access to anticipatory medications as her condition deteriorated. Upon reflection, Chris had less anxiety about the deterioration of her health because she had confidence that her symptoms would be managed under the CMP. It allowed the supplementary prescriber to titrate doses according the presenting symptoms. Recognition was given to the fact that Chris had never taken opioid analgesia and she was commenced on a low dose which was titrated according to her pain and breathlessness. Interestingly, the three anticipatory medications used all have multi-faceted pharmacodynamic effects within the body. Whilst it is suggested that levomepromazine used to treat nausea may also control pain and anxiety more robust research needs to be carried out as most of the evidence supporting its use in palliative care is anecdotal and based upon professional opinion. Whilst it is recognised that these medications could have been prescribed independently, the use of a CMP provided support to the prescribers, and through regular review it allowed the medical clinician to remain a partner within the prescribing relationship.