Alexis Fong-Leboeuf – Children’s Hospital of Eastern Ontario, Roger Neilson Children’s Hospice, University of Ottawa, Canada – Dr. Alexis Fong-Leboeuf is a subspecialty resident in her second year of Pediatric Palliative Care training at the Children’s Hospital of Eastern Ontario, having completed her initial pediatrics residency at Dalhousie University. Alexis is passionate about cultural safety and quality improvement in pediatric palliative care.
Feature Articles
Patel, B. (2024). Paediatric Palliative Care and Anticipatory Prescribing: Just Wasteful Are We? BMJ Paediatrics Open, 8, A29.
Commentary
In the published abstract, “Pediatric Palliative Care and Anticipatory Prescribing: just wasteful are we?”, author Bhumik Patel describes a retrospective chart review in a single pediatric centre; evaluating prescribing practices over an 8 month period to assess the difference in anticipatory medications ordered and medication utilized to assess for “wastage”, with a cost analysis conducted.
Patel provides a breakdown of the most prescribed enteral medications: opioids (57.5%), midazolam (17.5%), ketamine/glycopyrrolate (15%) and injectable medications: opioids (81%), midazolam (59%), and levomepromazine (11%). The implication from this abstract is that approximately 76.3% of the medications prescribed and dispensed were wasted, in addition to the equivalence of an environmental cost of 3,875 grams of CO2e (carbon dioxide equivalent) over the study period, for the 69 patients included.
Still fresh amidst the transition from General Pediatrics to Pediatric Palliative care, this article stood out to me; identifying a difference in pediatric palliative care (PPC) prescribing practices that never existed in the same way on the clinical teaching unit. “Anticipatory prescribing”, a practice common in PPC, is defined by the National Institute of Health and Care Excellence (NICE) as prescription in anticipation of symptoms, designed to enable rapid relief at whatever time the patient develops distressing symptoms.1 Drugs prescribed in anticipation may include previous or current prescriptions, sometimes with a change in route of administration, and newly prescribed drugs for anticipated new symptoms.1 A foundational tenet of PPC is preparation – for example, planning for a variety of symptoms that one may expect with variable disease entities. Often working in PPC elicits a familiarity with learning to expect the unexpected, and to prepare as such to help prevent suffering at the end of life. Sometimes this means ordering medications or quantities of medication that the patient doesn’t need at current, but may need in the future. This is particularly true of providers caring for patients at end-of-life in the community, where medication changes are more challenging to make outside of standard business hours.
While brief, this article certainly elicited reflection of my own stewardship practices, the meaning of stewardship, and it’s role in medicine and palliative care. The concept of “wastefulness” in this abstract is certainly an interest concept when the potential alternative is patient suffering. While anticipatory prescribing is an important component of palliative care – there must be a balance between drug stewardship and the risk of untimely symptom control. With this question in mind, I dug deeper, but was disappointed by the paucity of research in this area.
There are few studies examining anticipatory prescribing practices in palliative care, and even fewer in pediatric palliative care. A recent systematic review (Bowers, 2023), only focusing on the adult population, found a paucity of information in this area. While anticipatory prescribing is a practice widely recommended by a variety of organizations and institutions, many of these practices are based only on healthcare provider perceptions with little information or evidence about how these medications are prescribed, dispensed, utilized, and disposed of.2 They found only one study that looked at patient attitudes towards anticipatory prescribing at end-of-life, and a handful that addressed family and caregiver perception – generally viewed favourably in allowing for improved symptom control, autonomy, and empowerment, but with variable to no information on medication wastage and disposal. Interestingly, Bowers (2023) describes anticipatory prescribing as a relatively low-cost intervention – which garners the question – what is “low-cost”, and again, how do you balance carbon cost or financial cost with human suffering?
Furthermore, it is imperative to reflect on the primary objective of anticipatory prescribing; to avoid unnecessary patient distress, and how anticipatory prescribing seeks to address this. Anticipatory prescribing while simple in principle, is often complicated by the availability of medications, how it is delivered/received to/by the family, and who can administer these medications; all factors that may contribute to delays in symptom relief and work against the goals we aim to achieve.
In summary, Patel (2024) provides a brief foray into the exploration of anticipatory prescribing in pediatric palliative care, and has shed light on the paucity of research in this area. While Bowers (2023) provides a systematic review of adult palliative care practice, there lacks high level data for systems level cost, burden to the healthcare system, and impact on patient and caregivers. Ultimately, I have more questions than answers, but hope that this commentary has incited some reflection into your own anticipatory prescription practices and the unforeseen implications that manifest once your pen leaves the paper.
Additional References
- National Clinical Guideline Centre (UK). (2015). Care of Dying Adults in the Last Days of Life. National Institute for Health and Care Excellence (NICE).
- Bowers, B., Ryan, R., Kuhn, I., & Barclay, S. (2019). Anticipatory prescribing of injectable medications for adults at the end of life in the community: A systematic literature review and narrative synthesis. Palliative medicine, 33(2), 160–177. https://doi.org/10.1177/0269216318815796
View the 2024 Issue #6 Citation List in Library