Non-medical prescribing in palliative care: A regional survey

Ziegler, L. et al. Non-medical prescribing in palliative care: A regional survey. Palliative Medicine 2015 Feb;29(2):177-81


Background: The United Kingdom is considered to be the world leader in nurse prescribing, no other country having the same extended non-medical prescribing rights. Arguably, this growth has outpaced research to evaluate the benefits, particularly in areas of clinical practice where patients have complex co-morbid conditions such as palliative care. This is the first study of non-medical prescribing in palliative care in almost a decade.

Aim: To explore the current position of nurse prescribing in palliative care and establish the impact on practice of the 2012 legislative changes.

Design: An online survey circulated during May and June 2013. Participants: Nurse members (n = 37) of a regional cancer network palliative care group (61% response rate).

Results: While this survey found non-medical prescribers have embraced the 2012 legislative changes and prescribe a wide range of drugs for cancer pain, we also identified scope to improve the transition from qualified to active non-medical prescriber by reducing the time interval between the two.

Conclusion: To maximise the economic and clinical benefit of non-medical prescribing, the delay between qualifying as a prescriber and becoming an active prescriber needs to be reduced. Nurses who may be considering training to be a non-medical prescriber may be encouraged by the provision of adequate study leave and support to cover clinical work. Further research should explore the patients’ perspective of non-medical prescribing.


Factors affecting the successful implementation and sustainability of the Liverpool Care Pathway for dying patients: A realist evaluation

McConnell, T. et al. Factors affecting the successful implementation and sustainability of the Liverpool Care Pathway for dying patients: a realist evaluation. BMJ Supportive and Palliative Care Online – 7 November 2014

The Liverpool Care Pathway (LCP) for the dying patient was designed to improve end-of-life care in generalist healthcare settings. Controversy has led to its withdrawal in some jurisdictions.

The main objective of this research was to identify the influences that facilitated or hindered successful LCP implementation. There is a need to appreciate the organisationally complex nature of intervening to improve end-of-life care.

Successful implementation of evidence-based interventions for end-oflife care requires commitment to planning, training and ongoing review that takes account of different perspectives, institutional hierarchies and relationships, and the educational needs of professional disciplines. There is a need also to recognise that medical consultants require particular support in their role as gatekeepers and as a lead communication channel with patients and their relatives.

Conducting research interviews with bereaved family carers: When do we ask?

Bentley, Band O’Connor, M. Conducting Research Interviews with Bereaved Family Carers: When Do We Ask? Journal of Palliative Medicine. March 2015, 18(3): 241-245.

Interviews with bereaved family carers to examine the end-of-life experience of the deceased are important tools for palliative care researchers, but the ethics of approaching the bereaved when they are grieving and vulnerable is often debated.

The aim of this study was to explore the insights of bereaved family carers about the most appropriate time to be involved in a research interview about the end of life and death of their family member. Most family carers (86%) [interviewed] feel comfortable being interviewed about the death of their family member within the first 5 months of bereavement, with 43% reporting they could be interviewed within weeks after death.

Family carers reported that recall would be better earlier in bereavement and felt it may be helpful to them to talk about their experiences earlier. They said bereaved people should be allowed to decide for themselves when to be involved in an interview. These findings indicate that interviews with the bereaved may be most fruitful for researchers and beneficial to family carers when they are allowed to make the choice about timing for themselves, beginning weeks after the death of their family member.

Embracing a broad spirituality in end-of-life discussions and advance care planning

Churchill, L. Embracing a Broad Spirituality in End of Life Discussions and Advance Care Planning. Journal of Religion and Health Online – 18 December 2014.

A broad view of spirituality is needed, one that may involve traditional religious beliefs, but also includes personal understandings of what is holy or sacred. Embracing this broad practice of spirituality will help both familial and professional caregivers honour an essential aspect of endof-life discussions and promote greater discernment of the deep meaning in advance care documents.

Doctors’ and nurses’ views and experience of transferring patients from critical care home to die: A qualitative exploratory study

Coombs, M. et al. Doctors’ and nurses’ views and experience of transferring patients from critical care home to die. Palliative Medicine Online – 17 December 2014

The practice of transferring critically ill patients home to die is a rare event in the U.K., despite the positive view of health care professionals. Challenges to service provision include patient care needs, uncertain time to death, and the view that transfer to community services is a complex, highly time-dependent undertaking.

While there is evidence of this choice being honoured and delivered for some of the critical care population, it remains debatable whether this will become a conventional practice in end of life in this setting.

Current challenges in palliative care provision for heart failure in the U.K. A survey on the perspectives of palliative care professionals

Cheang, M.H. et al. Current challenges in palliative care provision for heart failure in the UK. Openheart Online – 16 January 2015

Reported rates of collaboration in three different cohorts—all respondents, consultants and non-consultant staff.

Objective: Palliative care (PC) in heart failure (HF) is beneficial and recommended in international HF guidelines. However, there is a perception that PC is underutilised in HF in the UK. This exploratory study aims to investigate, from a PC perspective, this perceived underutilisation and identify problems with current practice that may impact on the provision of PC in HF throughout the UK.

Methods: A prospective survey was electronically sent to PC doctors and nurses via the UK Association for Palliative Medicine and adult PC teams listed in the UK Hospice directory.

Results: We received 499 responses (42%—PC consultants). Although PC provision for patients with HF was widespread, burden on PC services was low (47% received less than 10 referrals annually). While PC was acknowledged to have a role in end-stage HF, there were differing views about the optimal model of care. Levels of interdisciplinary collaboration (58%) and mutual education (36%) were low. There were frequent reports that end-of-life matters were not addressed by cardiology prior to PC referral. Moreover, 24% of respondents experienced difficulties with implantable cardioverter defibrillator deactivation.

Conclusions: Low HF referrals despite widespread availability of PC services and insufficient efforts by cardiology to address PC issues may contribute to the perception that PC is underutilised in HF. The challenges facing PC and HF identified here need to be further investigated and addressed. These findings will hopefully promote awareness of PC issues in HF and encourage debate on how to improve PC support for this population.

Difficult Conversations: From Diagnosis to Death

Joel D. Marcus and Frank E. Mott. Difficult Conversations: From Diagnosis to Death.The Ochsner Journal: Winter 2014, Vol. 14, No. 4, pp. 712-717

Although many published guidelines address difficult communication, communication training is lacking. Consequently, many clinicians may have difficulties with, or in the worst-case scenario, avoid delivering bad news and discussing end-of-life treatment. Clinicians also struggle with how to have the last conversation with a patient and how to support patient autonomy when they disagree with a patient’s choices.

There is a clinical imperative to educate physicians and other healthcare workers on how to effectively deliver information about a patient’s health status, diagnostic avenues to be explored, and decisions to be made at critical health junctions. Knowing how to implement the most rudimentary techniques of motivational interviewing, solution-focused brief therapy, and cognitive behavioral therapy can help physicians facilitate conversations of the most difficult type to generate positive change in patients and families and to help them make decisions that minimize end-of-life distress.