Between paradox and prescribing: Understanding anticipatory prescribing at the end of life in UK care homes

Abstract

Background: In the United Kingdom, there has been a widespread introduction of anticipatory prescribing, especially in care home-based palliative care. Early and appropriate prescribing and administration of anticipatory medicines for patients who require end-of-life symptom control has become established good practice in palliative and end-of-life care policy. In care homes, the intervention aims to ensure timely symptom control, reassure residents and family members, and avoid emergency hospital admissions. However, there is limited evidence about how the anticipatory prescribing system—including its bureaucracy, regulatory apparatus, and the processes involved including the prescribing, dispensing, procurement, administration, monitoring, storage, and disposal of anticipatory medicines—unfolds in these contexts and stakeholder perspectives have not been sufficiently investigated. In 2015, the National Institute for Health and Care Excellence issued guidelines on the care of dying adults and specifically highlighted the need for empirical research into the use of anticipatory medicines in practice. Despite substantial developments in the literature since then, the evidence base supporting the implementation of anticipatory prescribing remains limited, particularly in care home settings. This research responds to this call. Aims: The study aims to expand understanding of the anticipatory prescribing system in care homes and the experiences and challenges of health and social care professionals within it, specifically by exploring: The underlying systemic tensions and wider interprofessional contexts which underpin issues related to the wastage and shortage of anticipatory medicines in care homes; the algorithmic and discursive structures which shape the tensions between individualisation and standardisation in end-of-life care; and the structural logics underpinning prescribing paperwork and how they contribute to the tension between navigating bureaucratic regulations and providing good, patient-centred end-of-life care in care homes. Methods: This thesis was underpinned by a constructivist, relativist approach and paradox perspective. A systematic literature review was conducted to synthesise understanding of the prescribing, storage, administration, monitoring, and disposal of controlled drugs for end-of-life care for care home residents in the United Kingdom. The findings from the review informed the design of the qualitative interview study. In total, 42 interviews were conducted with health and social care professionals working in 29 care homes. Reflexive Thematic Analysis of the qualitative dataset was informed by Braun and Clarke (2006, 2019, & 2021). All participants provided informed consent. Ethical approval was obtained from the University of Cambridge. Findings: Analysis revealed that the paradoxical occurrence of simultaneous anticipatory medicines wastage and shortage in care homes was rooted in poor interprofessional relationships and a contradiction between the mechanism of prescribing and the inherent uncertainty of the end of life; that care home residents going through the inherently individualized process of dying were often paradoxically treated in a standardised fashion via the use of prescribing protocols, standard anticipatory medicines packs, and nonspecific clinical language; and that anticipatory prescribing paperwork was constitutionally predisposed towards duplication, the multiplication of error categories, and the usurpation of time which could have been spent providing high-quality care to residents, something which it also paradoxically demanded. Conclusion: The study highlights the complexity of and key paradoxes within the anticipatory prescribing system in care homes. Robust professional relationships can provide a platform for effective communication, interprofessional collaboration, collective reflection on its various processes, its bureaucracy, and its role in end-of-life care. Moreover, such relationships can play a crucial role in establishing opportunities for training, securing sufficient resources, and offering support for professionals involved in anticipatory prescribing. The findings can inform future strategies aimed at improving the quality of end-of-life care within care homes in the United Kingdom.