fylde wyre ccg jic meds service appendix - psnc main site · 22 march 2013 16 april 2015 which...

Document Type: POLICY

Unique Identifier: CORP/POL/452

Title: Policy for Anticipatory Prescribing for Palliative Care Patients (Just in Case 4 Core Drugs)

Version Number: 4

Status: Draft

Scope: Trust Wide

Classification: Organisational

Author/Originator and title: Andrew Dickman – Consultant Pharmacist, Blackpool Teaching Hospitals NHS Foundation Trust Susan Salt – Consultant in Palliative Medicine, Trinity Hospice

Responsibility: Pharmacy

Replaces: Policy for Anticipatory Prescribing for Palliative Care Patients (Just in Case 4 Core Drugs) version 2 NL/QSE/08/09, Version 1, Just In Case Drugs Policy in Community (North Locality Only)

Description of amendments: Diamorphine changed to morphine as core drug Revised text around JiCDs and EoLAD

Name Of: Divisional/Directorate/Working Group:

Date of Meeting:

Risk Assessment: Not Applicable

Financial Implications Not Applicable

Validated by: Fylde Coast Health Care Economy Just in Case 4 Core Drugs Task and Finish Group Cumbria and Lancashire Palliative Care Medicines Management Group Adults and Long Term Conditions Policies and Standards Group

Validation Date: 02 April 2012 02 May 2012 22 March 2013 16 April 2015

Which Principles of the NHS Constitution Apply? Principle 1-4

Ratified by: Medicines Management Committee

Ratified Date:

Issue Date:

Review dates may alter if any significant changes are made Review Date:

Does this document meet the requirements of the Equality Act 2010 in relation to Race, Religion and Belief, Age, Disability, Gender, Sexual Orientation, Gender Identity, Pregnancy & Maternity, Marriage and Civil Partnership, Carers, Human Rights and Social Economic Deprivation discrimination? Initial Assessment

Blackpool Teaching Hospitals NHS Foundation Trust ID No. CORP/POL/452


Revision No: 4 Next Review Date:

Do you have the up to date version? See the intranet for the latest version

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CONTENTS

1 PURPOSE ................................................................................................................... 3

2 SCOPE ........................................................................................................................ 4 2.1 2.1 Issue of Just in case medication (in a tamper proof bag for patients registered

with a GP in Blackpool or Fylde and Wyre CCG only) ............................................ 4 2.2 Issue of Just in case medication BUT NOT in a tamper proof bag .......................... 4

3 POLICY ....................................................................................................................... 5 3.1 End of life anticipatory drugs (EoLAD) .................................................................... 5 3.2 Safe Destruction of unused Just in case or end of life medication .......................... 5 3.3 Circumstances where there may be concerns around the issue of Just in case or

End of life medication and further risk assessments may be needed ...................... 6 3.4 Exclusions ............................................................................................................... 6 3.5 Known Risks ........................................................................................................... 6

4 ATTACHMENTS ......................................................................................................... 7

5 ELECTRONIC AND MANUAL RECORDING OF INFORMATION .............................. 7

6 LOCATIONS THIS DOCUMENT ISSUED TO ............................................................. 7

7 OTHER RELEVANT/ASSOCIATED DOCUMENTS .................................................... 7

8 SUPPORTING REFERENCES/EVIDENCE BASED DOCUMENTS ........................... 8

9 CONSULTATION WITH STAFF AND PATIENTS ....................................................... 9

10 DEFINITIONS/GLOSSARY OF TERMS.................................................................... 10

11 AUTHOR/DIVISIONAL/DIRECTORATE MANAGER APPROVAL ............................ 10

Appendix 1: ‘Just in Case 4 Core Drugs’ for the End of Life: Indication for Use ............... 11

Appendix 2: Risk Assessment Tool Where There Is Concern About The Use Of “Just In Case Drug Policy” ..................................................................................................... 14

Appendix 3: Patient Information Leaflet around “Just In Case Drug Policy”....................... 16

Appendix 4: List of Participating Pharmacies in dispensing “Just in Case Drugs” ............. 20

Appendix 5: Equality Impact Assessment Form ................................................................. 22





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1 PURPOSE Patients with a progressive life limiting illness may experience new or worsening symptoms as their condition deteriorates. Equally as the end of their life approaches they may not be able to take oral medications which have been required to maintain their symptom control. Rapid access to appropriate parenteral medication which can be administered in a timely manner is widely accepted as one way to avoid unnecessary admissions to hospital in the last days of life. The provision of such medication also contributes to individuals being able to remain in their preferred place of care (DOH 2004, NICE 2004, GSF 2010). This policy, along with clinical prescribing guidelines (see Appendices 1), seeks to deliver optimal care to patients with a known progressive life limiting illness in the community by encouraging appropriate prescription of “just in case medication” which can be used to manage changes in a patient’s condition as they deteriorate. The “just in case 4 core drugs” enable the management of the majority of anticipated symptoms that may arise in the last few weeks / days of life including:

Pain.

Nausea and or vomiting.

Respiratory tract secretions.

Terminal restlessness and or agitation.

Breathlessness. “Just in Case 4 Core Drugs” (JiCDs) medicines are prescribed for the patient and supplied for storage in the patient’s home in anticipation and in advance of the need to administer the medicine ideally in the last few weeks / months of life. At the time of supply, the JiCDs are prescribed in the “Subcutaneous ‘as required’ and Syringe Pump Prescription Administration Record (SPAR booklet)”, so that they can be administered by the community nursing team in a timely manner if symptoms occur. In Lancashire North CCG area , the JiCDs are prescribed on the JiCD medication authorisation sheet (JiCD MARS) Prescribing the JiCDs does not mean that it is expected that the medication prescribed will definitely be used so carers and patients should re-assured that the prescribed medicines have been prescribed “just in case” and may not be needed. The quantity of medication supplied will only be sufficient for the first 24-48 hours and so the team involved in the patient’s care must plan ahead to ensure an adequate supply of medication is prescribed and dispensed to manage a patient’s on-going symptoms and condition including the on-going use of a syringe driver. All dispensed but unused medication, including unopened JiCDs must be returned to a pharmacy for destruction by a family member or individual important to the patient. Ideally this will be the dispensing pharmacy but if not possible the nearest local pharmacy. This policy may be used in conjunction with the Individualised plan of care for the Dying Person Guidance.





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2 SCOPE Patients, living in their own homes, with a progressive, life limiting illness, registered with a General Practitioner (GP) within Blackpool or Fylde and Wyre Clinical Commissioning Groups (CCGs), who have been assessed as in the last months / weeks or days of their life, may be included within this scheme. This will include patients with a poor prognosis, where the condition is unpredictable or is likely to deteriorate rapidly. Particular consideration should be given to those living in isolated situations or during extended holiday periods, where access to medication may be restricted. It will also apply to patients cared for by community staff employed by Blackpool Teaching Hospitals NHS Foundation Trust who work with GPs from Lancashire North CCG. In these circumstances the principles behind prescribing and administering Just in Case medication will be the same, however the actual medications prescribed “just in case” may include Cyclizine for nausea and /or vomiting rather than Levomepromazine. It will also apply to patients cared for by community staff employed by Blackpool Teaching Hospitals NHS Foundation Trust who work with GPs from Greater Preston CCG who work in the Great Eccleston Area. In these circumstances the principles behind prescribing and administering Just in Case medication will be the same, however the actual medications prescribed “just in case” may vary and include Cyclizine for nausea and /or vomiting rather than Levomepromazine and Hyoscine Hydrobromide rather than Glycopyrronium for respiratory tract secretions. 2.1 2.1 Issue of Just in case medication (in a tamper proof bag for patients

registered with a GP in Blackpool or Fylde and Wyre CCG only) The JiCDs scheme will include all patients, living in their own homes with a known progressive life limiting illness. They must be:

Registered with a General Practitioner (GP) within Blackpool, Lancashire North or Fylde and Wyre Clinical Commissioning Groups (CCGs).

Supported by District Nurses and / or Specialist Palliative Care Nurses.

Assessed as being in the last few months / weeks / days of life or where the patient’s condition is unpredictable or is likely to deteriorate rapidly. Careful consideration should be given to those living in isolated situations or during extended holiday periods.

Ideally on the GP end of life register. 2.2 Issue of Just in case medication BUT NOT in a tamper proof bag Patients residing in care home establishments, due to Misuse of Drugs Act storage requirements. Palliative care medicines can be supplied as per normal dispensing supply (not in tamper-evident bag). They must be:

Registered with a General Practitioner (GP) within Blackpool, Lancashire North or Fylde and Wyre Clinical Commissioning Groups (CCGs).





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Assessed as being in the last few months / weeks / days of life or where the patient’s condition is unpredictable or is likely to deteriorate rapidly. Careful consideration should be given to those living in isolated situations or during extended holiday periods.

Ideally on the GP end of life register. Only the designated pharmacies (see Appendix 4) should be used to dispense JiCDs, as an anticipatory supply (in a tamper-evident bag for secure storage in patient’s homes Blackpool or Fylde and Wyre CCG’s only). The JiCDs have been chosen for the locality because they are consistent with the prescribing algorithms of the local individualised plan for the dying person. These drugs are:

Morphine for pain or breathlessness

Glycopyrronium for respiratory tract secretions.

Levomepromazine (or Cyclizine for LNCCG residents) for nausea and or vomiting.

Midazolam for agitation, breathlessness and / or terminal restlessness. 3 POLICY 3.1 End of life anticipatory drugs (EoLAD) In the case of patient intolerance of one of the four core drugs, alternative medications may be prescribed following local symptom control guidance. A 5 days’ supply of such should be prescribed on FP10 or hospital discharge prescription and the SPAR booklet, JiC Medicines Authorisation sheet completed to allow its administration. These end of life anticipatory drugs (EoLAD) will be supplied as part of the normal dispensing supply (which in the community can be obtained from any community pharmacy), although stock cannot always be guaranteed. Patients discharged from hospital will receive these drugs in a tamper proof bag, but drugs dispensed in the community will not be issued in a tamper proof bag. 3.2 Safe Destruction of unused Just in case or end of life medication All medication that

Has not been used once the patient has died.

No longer needed because the patient has improved.

Has passed its expiry date. The medication must be returned to a pharmacy for safe destruction by a family member. Only in exception circumstances should the medication be removed from the home by a healthcare professional and returned to a pharmacy for destruction. This will be made clear in the patient information leaflet and verbally by staff when the JiCD or EoLAD are issued.





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3.3 Circumstances where there may be concerns around the issue of Just in case or End of life medication and further risk assessments may be needed

Patients where there is a history or suspicion of drug misuse.

Patients with family members, carers or visitors to the house where there is a history or suspicion of drug misuse.

Patients where there is concern about the safe storage of the medication.

Patients where there is concern about the medication being accessed by children or other vulnerable members of the household.

Patients where there are concerns about the mental well-being of a member of the patient’s household or regular visitor where access to a controlled drug could be contra-indicated such as suicidal ideation.

In these situations each case must be individually reviewed and a risk assessment (see Appendix 2) carried out by a senior member of the primary care team before a decision is made after a multi-disciplinary discussion which should involve as a minimum.

Patient’s GP.

Senior District Nurse.

Specialist in Palliative Care.

(Drug support worker if involved). It is anticipated that in most cases the decision will made be to provide just in case or end of life medication but that additional safeguards may be needed such as more frequent checking or adjusting the timing of such medication being placed in the household. The decision and risk assessment should be reviewed on a regular basis, the frequency of which will depend on the individual patient and rate of deterioration. 3.4 Exclusions Patients who themselves are unwilling to participate or carers who are unwilling to participate. If there are concerns advice should be sought from the Specialist Palliative Care services i.e. Trinity Hospice / St John’s Hospice. 3.5 Known Risks

Misuse of the drugs. An untoward incident report (CORP/PROC/101) must be completed if there is suspicion of misuse along with completion of a risk assessment form as per Appendix 2.

Opioid toxicity due to inappropriate dose being administered. Most patients requiring the “Just in Case” drugs will be opioid tolerant so the risk of overdose is small. In the rare instance of a suspected opioid overdose, seek medical advice. An untoward incident report (CORP/PROC/101) must be completed if there is suspicion that opioid doses have resulted in toxicity.

Undue sedation due to use of midazolam and / or combination of midazolam and





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opioid. In the rare instance of suspected over sedation seek medical advice. An untoward incident report (CORP/PROC/101) must be completed if there is suspicion of over sedation due to medication.

Safe disposal of unused vials of either JiCD or EoLAD after the death of an individual in their own home relies on a carer returning the unused vials to a community pharmacy for safe disposal. Whilst this can be encouraged it cannot be guaranteed.

Medication may reach expiry date before it is needed. It is essential that both JiCD and EoLAD medication is regular checked to ensure it is within date. This is particularly important prior to holiday periods or where an individual lives in a relatively isolated location.

4 ATTACHMENTS

Appendix Number Title

1 ‘Just in Case 4 Core Drugs’ for the End of Life: Indications for Use and Guidelines

2 Risk assessment risk assessment tool where there is concern about the use of “just in case drug policy”

3 Patient information leaflet

4 List of Participating Pharmacies

5 Equality Impact Assessment Form

5 ELECTRONIC AND MANUAL RECORDING OF INFORMATION

Electronic Database for Procedural Documents

Held by Policy Co-ordinators/Archive Office

6 LOCATIONS THIS DOCUMENT ISSUED TO

Copy No Location Date Issued

1 Intranet

2 Wards, Departments and Service

7 OTHER RELEVANT/ASSOCIATED DOCUMENTS

Unique Identifier Title and web links from the document library

CHS/POL/001 Infection Prevention in the Community Setting http://fcsharepoint/trustdocuments/Documents/CHS-POL-001.docx

CHS/POL/003 Non Medical Prescribing http://fcsharepoint/trustdocuments/Documents/CHS-POL-003.docx

CHS/SOP/009 Supply and Administration of Controlled Drugs via a Syringe Driver in a Patient’s Premises http://fcsharepoint/trustdocuments/Documents/CHS-SOP-009.docx

CORP/GUID/143 Palliative Care Prescribing: Lancashire and South Cumbria Specialist Palliative Care Services 2014 http://fcsharepoint/trustdocuments/Documents/CORP-GUID-143.pdf

http://fcsharepoint/trustdocuments/Documents/CHS-POL-001.docx




http://fcsharepoint/trustdocuments/Documents/CHS-SOP-009.docx

http://fcsharepoint/trustdocuments/Documents/CHS-SOP-009.docx

http://fcsharepoint/trustdocuments/Documents/CORP-GUID-143.pdf

http://fcsharepoint/trustdocuments/Documents/CORP-GUID-143.pdf





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7 OTHER RELEVANT/ASSOCIATED DOCUMENTS

Unique Identifier Title and web links from the document library

CORP/GUID/145 Care for the Dying Person Interim Guidance http://fcsharepoint/trustdocuments/Documents/CORP-GUID-145.docx

CORP/POL/056 Hand Hygiene Policy http://fcsharepoint/trustdocuments/Documents/CORP-POL-056.doc

CORP/POL/116 Infection Prevention Policy http://fcsharepoint/trustdocuments/Documents/CORP-POL-116.doc

CORP/POL/509 Non-Medical Prescribing http://fcsharepoint/trustdocuments/Documents/CORP-POL-509.doc

CORP/PROC/101 Untoward Incident and Serious Incident Reporting http://fcsharepoint/trustdocuments/Documents/CORP-PROC-101.docx

CORP/PROC/302 Controlled Drugs – Safer Management of Controlled Drugs http://fcsharepoint/trustdocuments/Documents/CORP-PROC-302.docx

CORP/PROC/418 Hand Hygiene Procedure http://fcsharepoint/trustdocuments/Documents/CORP-PROC-418.doc

CORP/PROC/567 Health Record – Basic Clinical Record Keeping Standards http://fcsharepoint/trustdocuments/Documents/CORP-PROC-567.doc

CORP/PROC/583 Safe disposal of all medicines http://fcsharepoint/trustdocuments/Documents/CORP-PROC-583.doc

CORP/PROC/592 Procedure For Anticipatory Prescribing For Palliative Care Patients (Just In Case 4 Core Drugs) http://fcsharepoint/trustdocuments/Documents/CORP-PROC-592.docx

CORP/PROC/577 Use of CME T34 Syringe Pump for Adult Patients http://fcsharepoint/trustdocuments/Documents/CORP-PROC-577.doc

CORP/PROT/001 Non-medical prescribing Protocol and Policy http://fcsharepoint/trustdocuments/Documents/CORP-PROT-001.DOCX

8 SUPPORTING REFERENCES/EVIDENCE BASED DOCUMENTS

References In Full

Amass, C. and Allen, M. (2005) How a ‘Just in Case’ Approach can Improve Out-of-Hours Palliative Care Pharmaceutical Journal 275: 22

Amass, C. (2006) The Gold Standards Framework for Palliative Care in the Community. Pharmaceutical Journal 276: 353-354

Blackburn with Darwen & East Lancashire PCTs (2009) East Lancashire Guidelines For The Management Of Symptoms In The Last Days Of Life

http://fcsharepoint/trustdocuments/Documents/CORP-GUID-145.docx

http://fcsharepoint/trustdocuments/Documents/CORP-GUID-145.docx

http://fcsharepoint/trustdocuments/Documents/CORP-POL-056.doc






http://fcsharepoint/trustdocuments/Documents/CORP-PROC-101.docx




http://fcsharepoint/trustdocuments/Documents/CORP-PROC-418.doc


http://nltpct/providerservices/Documents/Clinical%20Record%20Keeping%20%20%20Clin21%20V3.0.pdf









http://fcsharepoint/trustdocuments/Documents/CORP-PROT-001.DOCX

http://fcsharepoint/trustdocuments/Documents/CORP-PROT-001.DOCX

http://www.pjonline.com/Editorial/20050702/articles/p22justincase.html

http://www.pjonline.com/Editorial/20050702/articles/p22justincase.html

http://www.rcpa.org.uk/MyFiles/Files/Palliative%20and%20End%20of%20Life%20Care/Mar%2006%20-%20Gold%20Standards%20Framework%20for%20Palliative%20Care%20in%20the%20Community.pdf

http://www.google.co.uk/search?hl=en&source=hp&biw=1003&bih=592&q=anticipatory+prescribing+blackburn&aq=f&aqi=&aql=&oq=

http://www.google.co.uk/search?hl=en&source=hp&biw=1003&bih=592&q=anticipatory+prescribing+blackburn&aq=f&aqi=&aql=&oq=





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8 SUPPORTING REFERENCES/EVIDENCE BASED DOCUMENTS

References In Full

Cambridgeshire Community Services NHS Trust (2010) Policy for Anticipatory Prescribing For Patients with a Terminal Illness

Department Of Health (2008) End of Life Care Strategy

Department of Health (2006) Safer Management Of Controlled Drugs: Guidance On The Destruction And Disposal Of Controlled Drugs (Interim Guidance) Gateway Reference: 7186

Department of Health (2004) Delivering the Out-of-Hours Review: Securing proper access to medicines in the out-of-hours period - a practical guide for PCTs and organised providers.

Gold Standards Framework GSF) Online. Birmingham. Available at http://www.goldstandardsframework.nhs.uk accessed on 11 February 2011 Lancashire and South Cumbria Cancer Network (2014) Palliative Care Prescribing

National Institute for Clinical Excellence (2004) Improving Supportive and Palliative Care for Adults with Cancer

National Patient Safety Agency (2008). Reducing Dosing Errors with Opioid Medicines NPSA/2008/RRR005

National Patient Safety Agency (2008). Reducing risk of Overdose with Midazolam Injection in Adults NPSA/2008/RRR011

National Patient Safety Agency (2010). Safer Ambulatory Syringe Drivers NPSA/2010/RRR019

National Prescribing Centre (2009) A Guide to Good Practice in the Management of Controlled Drugs in Primary Care. 3rd edition. London: Department of Health

Nursing and Midwifery Council (NMC) (2010) Standards for Medicines Management. London: NMC

9 CONSULTATION WITH STAFF AND PATIENTS

Name Designation

Dr Susan Salt Medical Director, Trinity Hospice and Palliative Care Services

Dr Laura Edwards Community Consultant in Palliative Medicine, Trinity Hospice and Palliative Care Services

Dr Andrea Whitfield Hospital Consultant in Palliative Medicine, Blackpool Teaching Hospitals NHS Foundation Trust

Dr Menakshi Varia GP and Macmillan GP Facilitator, Fylde and Wyre and Trinity Hospice and Palliative Care Services

Dr Michelle Martin GP and Macmillan GP Facilitator, Blackpool CCG and Trinity Hospice and Palliative Care Services

Kathryn Smith Fylde Coast End of life project lead

Lynn Atcheson Practice Development Practitioner, community

Lisa Drinkwater Fylde and Wyre CCG Development Pharmacist

Annette Ramesh Team Leader DN Fleetwood

Janet Purdie End of Life lead, Blackpool

Vivienne Trott End of life facilitator Fylde and Wyre, Trinity

Wendy Lambert Lead Nurse FCMS

Melanie Preston Lead Pharmacist Blackpool CCG

Jan Bamber Non-Medical Prescribing lead Blackpool Teaching Hospitals NHS Foundation Trust

http://www.dh.gov.uk/prod_consum_dh/groups/dh_digitalassets/@dh/@en/documents/digitalasset/dh_086345.pdf

http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_4139701



http://www.goldstandardsframework.nhs.uk/

http://www.cancerlancashire.org.uk/CubeCore/.uploads/website_content/Your%20Network/Document%20Library/PALLIATIVECAREPRESCRIBINGFINALVERSION2010.pdf

http://www.cancerlancashire.org.uk/CubeCore/.uploads/website_content/Your%20Network/Document%20Library/PALLIATIVECAREPRESCRIBINGFINALVERSION2010.pdf

http://www.nice.org.uk/nicemedia/live/10893/28816/28816.pdf

http://www.nice.org.uk/nicemedia/live/10893/28816/28816.pdf

http://www.nrls.npsa.nhs.uk/alerts/?entryid45=59888&q=0%c2%acopioid%c2%ac

http://www.nrls.npsa.nhs.uk/alerts/?entryid45=59896&p=2

http://www.nrls.npsa.nhs.uk/alerts/?entryid45=59896&p=2

http://www.nrls.npsa.nhs.uk/resources/type/alerts/?entryid45=92908

http://www.npc.nhs.uk/controlled_drugs/resources/controlled_drugs_third_edition.pdf

http://www.npc.nhs.uk/controlled_drugs/resources/controlled_drugs_third_edition.pdf

http://www.nmc-uk.org/Documents/Standards/nmcStandardsForMedicinesManagementBooklet.pdf





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9 CONSULTATION WITH STAFF AND PATIENTS

Name Designation

Julie Lonsdale Lead Pharmacist Fylde and Wyre CCG

Raymond Lea Chair of Lancashire Pharmacy Committee

Gill Speight Head of North Locality, Blackpool Teaching Hospitals NHS Foundation Trust

10 DEFINITIONS/GLOSSARY OF TERMS

CCGs Clinical Commissioning Groups

EoLAD End of life anticipatory drugs

GP General Practitioner

JiCDs Just in Case 4 Core Drugs

SLA Service Level Agreement

SPAR Subcutaneous ‘As Required’ & Syringe Pump Prescription and Administration Record

JiCD MARS Just in case drugs medicines authorisation sheet.

11 AUTHOR/DIVISIONAL/DIRECTORATE MANAGER APPROVAL

Issued By Dr Andrew Dickman Checked By A Gibson

Job Title Consultant Pharmacist, Palliative Care

Job Title Director of Pharmacy

Date Date





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Appendix 1: ‘Just in Case 4 Core Drugs’ for the End of Life: Indication for Use





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Appendix 1: ‘Just in Case 4 Core Drugs’ for the End of Life: Indication for Use

OTHER DRUGS THAT MAY BE USED IN CSCIs LOCALLY INCLUDE: Drug Dose Indication

Diamorphine If opioid naïve: 5 ‐ 10 mg/24 hour Pain (reserved for high doses)

Oxycodone If opioid naïve: 5 ‐ 10 mg/24 hour Pain

Hyoscine butylbromide (Buscopan) 40 ‐ 160 mg/24 hour Gastrointestinal colic / respiratory tract secretions

Metoclopramide 30 mg / 24 hour (higher doses on specialist advice)

Nausea & vomiting

Haloperidol 1.5 ‐ 5 mg/24 hour (max 10mg/24 hour) Nausea & vomiting

(Haloperidol 5 – 30 mg / 24 hour Agitation)

Cyclizine 50 ‐ 150 mg/24 hour (max 150 mg/24 hour) Nausea & vomiting

Hyoscine Hydrobromide 0.8 - 1.6 mg/24 hour (max 2.4 mg/24 hour) Respiratory tract secretions

Sodium chloride 0.9% for injection not with cyclizine Diluent

THE FOLLOWING DRUGS ARE TO BE USED ONLY ON THE RECOMMENDATION OF SPECIALIST PALLIATIVE CARE

(Levomperomazine 25 – 150 mg / 24 hour (may be lower on some

occasions) Agitation)

Octreotide 300 ‐ 900 micrograms/24 hour Obstructive vomiting

Ondansetron 8 ‐ 24 mg/24 hour (max 32 mg/24 hour) Refractory vomiting

Tramadol 50 ‐ 400 mg/24 hour Pain

Dexamethasone 2 ‐16 mg/24 hour Several uses, e.g. pain, nausea

THE FOLLOWING DRUGS ARE TO BE USED ONLY WITH THE DIRECT GUIDANCE OF A SPECIALIST IN PALLIATIVE CARE

Alfentanil Pain

Ketamine

Ketorolac

Methadone

Compatibility of Medicines in a Syringe Pump

The four core drugs recommended in this guidance are compatible to be used together in a syringe pump. Other drugs may or may not be compatible for use together. An online syringe pump compatibility tool is available at http://book.pallcare.info/index.php?op=plugin&src=sdrivers

If unsure, please seek further advice from local specialist palliative care team or hospice advice line

RESPIRATORY TRACT SECRETIONS

If the symptoms are not controlled, contact the Specialist Palliative Care Service for advice.

Treatment must be started as soon as symptoms appear. Drugs cannot remove already-present secretions. Consider positional change or use of suction.

No Yes Secretions present?

PRN

Glycopyrronium 200 micrograms

SC 4 hourly

Stat glycopyrronium 200 micrograms SC

Commence glycopyrronium 0.6-1.2 mg CSCI over 24 hours

Titrate dose as necessary; max dose 1.2 mg over 24 hours.

http://book.pallcare.info/index.php?op=plugin&src=sdrivers





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Appendix 2: Risk Assessment Tool Where There Is Concern About The Use Of “Just In Case Drug Policy”





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Appendix 3: Patient Information Leaflet around “Just In Case Drug Policy”





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Appendix 4: List of Participating Pharmacies in dispensing “Just in Case Drugs”

ONLY these designated pharmacies should be used for dispensing JiCDs in tamper

proof bags for Blackpool Fylde and Wyre

Community Pharmacies Participating in Anticipatory Supply of JiCD in Tamper-Evident Bag

Blackpool Cohens Pharmacy

Moor Park Health Centre Bristol Avenue Blackpool FY2 0JG Telephone 01253 354988

Blackpool MedicX Pharmacy

Whitegate Primary Care Centre 150 Whitegate Drive Blackpool FY3 9ES Telephone 01253 807808

Blackpool Co-op Pharmacy

9-11 All Hallows Road Bispham Blackpool FY2 0AS Telephone 01253 355699

Blackpool Lytham Road Pharmacy

South Shore Primary Care Centre Lytham Road Blackpool FY4 1TJ Telephone 01253 403038

Cleveleys/ Thornton Boots Pharmacy

39 Victoria Road Cleveleys FY5 1BS Telephone 01253 853168

Kirkham Co-op Pharmacy

5 Market Square Kirkham PR4 2SE Telephone 01772 686118

Fleetwood Warburtons Chemist

84-86 Lord Street Fleetwood FY7 6JZ Telephone 01253 874849

Poulton / Carleton Carleton Pharmacy

5 Poulton Road Carleton FY6 7NH Telephone 01253 896878

Freckleton Co-op Pharmacy

Trinity Medical Centre Douglas Drive Freckleton PR4 1RY Telephone 01772 632347

St Anne’s / Lytham MedicX Pharmacy

Lytham Health Centre Warton Street Lytham FY8 5EE Telephone 01253 737695

Great Eccleston Great Eccleston Health Centre Pharmacy

Raikes Road Great Eccleston PR3 0ZA Telephone 01995 672925

Hambleton Hambleton Pharmacy

Kiln Lane Hambleton FY6 9AH Telephone 01253 702219

Out Of Hours Access to End of Life Drugs (for use in EMERGENCIES only)

Fylde Coast Medical Services

via Urgent Care Centre at Blackpool Teaching Hospital

01253 956488

Preston Primary Care Centre

01772 788058





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Appendix 4: List of Participating Pharmacies in dispensing “Just in Case Drugs”

Participating Pharmacies in Lancashire North

Area Address Telephone Number

Carnforth Co- op Pharmacy, 9, Market Street Carnforth LA5 9JX

01524 722712

Morecambe/Heysham Cohens Pharmacy 1, Heysham Road, Morecambe LA31DA

01524 412275

Lancaster ASDA Pharmacy Ovangle Road, Lancaster LA15JR

01524 841042

Garstang Kepple Lane Pharmacy Garstang Medical Centre Kepple Lane Garstang PR31PB

01992 604800

Appendix 5: Equality Impact Assessment Form Department Pharmacy Service or Policy CORP/POL/452 Date Completed: 25/05/2015

GROUPS TO BE CONSIDERED Deprived communities, homeless, substance misusers, people who have a disability, learning disability, older people, children and families, young people, Lesbian Gay Bi-sexual or Transgender, minority ethnic communities, Gypsy/Roma/Travellers, women/men, parents, carers, staff, wider community, offenders.

EQUALITY PROTECTED CHARACTERISTICS TO BE CONSIDERED Age, gender, disability, race, sexual orientation, gender identity (or reassignment), religion and belief, carers, Human Rights and social economic / deprivation.

QUESTION RESPONSE IMPACT

Issue Action Positive Negative What is the service, leaflet or policy development? What are its aims, who are the target audience?

See Purpose

Does the service, leaflet or policy/ development impact on community safety

Crime

Community cohesion

No

Is there any evidence that groups who should benefit do not? i.e. equal opportunity monitoring of service users and/or staff. If none/insufficient local or national data available consider what information you need.

No

Does the service, leaflet or development/ policy have a negative impact on any geographical or sub group of the population?

No

How does the service, leaflet or policy/ development promote equality and diversity?

No

Does the service, leaflet or policy/ development explicitly include a commitment to equality and diversity and meeting needs? How does it demonstrate its impact?

No

Does the Organisation or service workforce reflect the local population? Do we employ people from disadvantaged groups

No

Will the service, leaflet or policy/ development i. Improve economic social conditions

in deprived areas

ii. Use brown field sites iii. Improve public spaces including

creation of green spaces?

No

Does the service, leaflet or policy/ development promote equity of lifelong learning?

No

Does the service, leaflet or policy/ development encourage healthy lifestyles and reduce risks to health?

No

Does the service, leaflet or policy/ development impact on transport? What are the implications of this?

No

Does the service, leaflet or policy/development impact on housing, housing needs, homelessness, or a person’s ability to remain at home?

No

Are there any groups for whom this policy/ service/leaflet would have an impact? Is it an adverse/negative impact? Does it or could it (or is the perception that it could exclude disadvantaged or marginalised groups?

No

Does the policy/development promote access to services and facilities for any group in particular?

No

Does the service, leaflet or policy/development impact on the environment

During development

At implementation?

No





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Appendix 5: Equality Impact Assessment Form ACTION:

Please identify if you are now required to carry out a Full Equality Analysis

Yes No (Please delete as appropriate)

Name of Author: Signature of Author:

Dr Andrew Dickman / Dr Susan Salt Date Signed: 25/05/2015

Name of Lead Person: Signature of Lead Person:

Date Signed:

Name of Manager: Signature of Manager

Date Signed: