insert publication title here

COVID-19

Palliative Care

Toolkit

Palliative Care Toolkit, version 2.2

2

Purpose The purpose of this palliative care toolkit is to provide Health Board planners with

support for local resilience planning during the COVID-19 pandemic. It is not

intended to replace existing palliative care processes and guidance documents but

instead it offers a range of practical approaches and tools that can be considered

and adapted locally in order to strengthen any local response to the COVID-19

situation.

The toolkit has been shared with a range of stakeholders for comment and has

been approved by the Scottish Government Professional Advisors Group (PAG) for

application during the COVID-19 outbreak.

The content of the toolkit will be reviewed post COVID-19 and consideration given

as to whether an adapted version should continue to be made available.

Version History Version Date Summary of changes

2.2 30/04/2020 Updated Appendix N title

Further Information For more information on COVID-19 see the COVID-19 guidance section of our

website, www.gov.scot/coronavirus

http://www.gov.scot/coronavirus


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Contents Purpose .......................................................................................................................................2

Version History .........................................................................................................................2

Further Information .................................................................................................................2

Contents ......................................................................................................................................3

Executive Summary..................................................................................................................5

Section one: COVID-19 Contingency Plan – Scottish Palliative Care Pharmacy

Association 9

Section two - Strengthening Primary Care........................................................................15

Section three - Accessing oral palliative care medicines from Emergency

Departments during COVID-19 ............................................................................................18

Section four - Accessing palliative care medicines in care homes ..............................24

Appendix A: Prescribing dose ranges for COVID-19 palliative care patients during

the pandemic ...........................................................................................................................31

Appendix B: Single Nurse Administration (SNA) of Controlled Drugs .........................35

Appendix C: the SPOT clinical decision prescribing support tool .................................39

Appendix D: Example of Guidance for Prescribing and Administering PRN

medication when a Person is Imminently Dying from COVID-19 Lung disease .......42

Appendix E: SAMPLE Drug Administration Instruction Chart (courtesy of NHS

Tayside) .....................................................................................................................................43

Appendix F: SAMPLE Medication Administration Record ..............................................46

Appendix G: SAMPLE Communications Sheet ...................................................................48

Appendix H: Example of Just in Case Box prescribing from NHS Tayside ................49

Appendix I: Patient Group Direction (PGD) template - supply of paracetamol

500mg oral solid dosage form to patients with COVID-19 approaching the end of

life requiring relief from pain or fever, by appropriate registered healthcare

professionals in NHSScotland...............................................................................................53

Appendix J: Patient Group Direction (PGD) template - supply of morphine sulfate

10mg/5ml oral solution to patients with COVID-19 approaching the end of life

requiring relief from pain, breathlessness or cough by appropriate registered

healthcare professionals in NHSScotland. .........................................................................61

Appendix K: Patient Group Direction (PGD) template - supply of lorazepam 1mg

tablets, to patients with COVID-19 approaching the end of life requiring relief

from anxiety and distress, by appropriate registered healthcare professionals in

NHS Scotland. ...........................................................................................................................70

Appendix L: Patient Leaflet - Supply of medicines for control of symptoms ...........78

Appendix M: Coronavirus in care homes – visual............................................................83


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Appendix N: Administration of palliative care medicine for care home residents at

end of life (courtesy of SPCPS based on a Model of Care developed by NHSGG&C)

....................................................................................................................................................84

Appendix O – Summary of issues to be considered to support care home residents

accessing palliative care medicines during the COVID-19 pandemic (courtesy of

SPCPS)........................................................................................................................................87

Appendix P – Members of Working Group for the Palliative Care Toolkit ................89


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Executive Summary The aim of this toolkit is to help improve access to supportive and palliative care

medicines, within the scope of the Human Medicines Regulations 2012, including

the flexibilities provided during a pandemic situation, and the Misuse of Drugs

Regulations 2001. The toolkit provides Health Board planners with options that

can be adapted and utilised locally in their response to COVID-19. To assist with

this, several exemplars of documentation, policies, charts and flow diagrams have

been included in the appendices.

Guidelines

The appropriate reduction of suffering for those who are very ill or dying from

COVID-19 is paramount. Normally, the Scottish Palliative Care guidelines are the

reference point for the management of adults with life limiting illness. More

recently, temporary guidelines for symptom management for when a person is

imminently dying from COVID-19 and for supporting end of life care when

alternatives to medication normally given through syringe pumps are required

have been developed.

The first of these two new guidelines describes the symptoms of COVID-19 and

the palliative care medicines to help alleviate symptoms, at the end of life. The

second guideline describes alternative palliative care medicines that that can be

prescribed in the event that there is a shortage of essential palliative care

medicines, syringe pumps or district nursing staff to administer sub-cutaneous

medicines. It aims to support professionals, who are already skilled in providing

generalist palliative care, in identifying alternatives medicines and routes of

administration, when usual medicines or syringe drivers are not available.

This toolkit aligns with these two temporary Scottish Palliative Care guidelines in

order to strengthen the response across primary and secondary care and in the

various care settings where people require palliative care.

Sections

The toolkit comprises the following four sections:

Section one: palliative care contingency planning overview;

Section two: strengthening Primary Care in-hours and out-of-hours;

Section three: discharge from an Emergency Department; and

Section four: providing medicines to care homes.

http://www.legislation.gov.uk/uksi/2012/1916/contents/made



https://www.palliativecareguidelines.scot.nhs.uk/

https://www.palliativecareguidelines.scot.nhs.uk/guidelines/symptom-control/end-of-life-care-guidance-when-a-person-is-imminently-dying-from-covid-19-lung-disease.aspx


https://www.palliativecareguidelines.scot.nhs.uk/guidelines/symptom-control/alternatives-to-regular-medication-normally-given-via-a-syringe-pump-when-this-is-not-available.aspx



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Section one contains a palliative care contingency plan which describes a series of

priority areas and potential solutions which Health Board planners may wish to

consider in order to build a tiered approach to strengthening the palliative care

pathway. The contingency plan takes into account the different care settings, the

varying demographic and geographic profiles of communities and any existing

palliative care service provision. It suggests who should lead on any actions and

timescales. Some of these activities are described in more detail in sections two,

three and four.

Section two describes a range of measures that can be used to strengthen the

response from primary care services both in-hours and out-of-hours as well as

securing and protecting the medicine supply chain in order to reduce any

preventable waste. Appendices A-H contain a number of practical tools to support

this.

Section three outlines a new alternative of ‘To Take Out’ (TTO) packs for oral

palliative medicines as a discharge option for an Emergency Department. This will

support a quick discharge home and allow a carer or relative to administer oral

medicines to help alleviate symptoms. This may provide a suitable bridge before

a ‘Just in Case Box’ (JICB) can be arranged in the community, if required. There is

also a one page quick reference guide. In addition, appendices I-L include three

Patient Group Direction (PGD) templates for local adoption to facilitate the supply

of the TTO medicines and a Patient Information Leaflet (PIL) for supply with the

medicines.

Section four describes a number of ways to support access to medicines in care

homes. In particular, there are options to consider how to expand the use of

homely remedies to provide symptomatic relief, ways to increase access to

certain Prescription Only Medicines (POMs) using health board approved protocols

and approaches such as using anticipatory prescriptions for JICBs for residents to

minimise the waste of critical medicines. Appendices M-O provide specific tools

to support this.

Appendices

Underpinning each of these sections are appendices which provide existing

exemplar guidance documents and templates that a number of Health Boards

have developed and agreed to share. These include, in addition to what has been

described above, information on the Safer Prescribing of Opioids Tool (SPOT), a

summary of the sample Medication Administration Record (MAR) charts, guidance


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on single nurse administration; guidance on the use of dose ranges; sample

communication sheets and district nurse administration sheets.

Reducing the risk of waste and avoidable medicine shortages

As a result of the global impact of COVID-19 there may be significant constraints

on the availability of a number of palliative care medicines. Throughout the

toolkit, there is an emphasis on approaches that minimise waste and reduce the

risk of avoidable medicine shortages. In addition, NHS England is developing

guidance on the repurposing of medicines in Care Homes and Hospices and NHS

Scotland will consider the outcome of this work when it is available.

Training

Additional guidance, training and support materials are available both through

Turas (NHS Education for Scotland) and various Royal Colleges and professional

bodies. One such example is the Royal College of General Practitioners’ guide on

Community Palliative, End of Life and Bereavement Care in the COVID-19

Pandemic.

Legislative considerations

There is an option to allow the supply of POMs to patients during the COVID-19

pandemic within the existing legislative provisions in the Human Medicines

Regulations 2012. Regulation 214 means a person may not supply a POM except

in accordance with a prescription given by an appropriate practitioner. However,

the Regulations also set out various exceptions to this rule. For example,

regulation 247 allows the supply of a POM without a prescription in a pandemic

situation, provided certain conditions are met. For example, the supply must be

made whilst a disease is, or in anticipation of a disease being imminently

pandemic and a serious risk, or potentially serious risk to human health. The

supply must be made under a disease specific protocol that specifies the

symptoms of and the treatment of that disease. The protocol must also be

approved by UK Ministers or an NHS body. “NHS body” includes territorial Health

Boards in Scotland. Any Health Board considering this approach will want to

satisfy themselves that any protocol complies with regulation 247 and the

legislation which sets out the requirements for controlled drugs, for example the

Misuse of Drugs Regulations 2001. The Central Legal Office (CLO) will be able to

provide Health Boards with advice on this.

https://elearning.rcgp.org.uk/pluginfile.php/149342/mod_resource/content/1/COVID%20Community%20symptom%20control%20and%20end%20of%20life%20care%20for%20General%20Practice%20FINAL.PDF

https://elearning.rcgp.org.uk/pluginfile.php/149342/mod_resource/content/1/COVID%20Community%20symptom%20control%20and%20end%20of%20life%20care%20for%20General%20Practice%20FINAL.PDF


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Local adoption

Health Boards may wish to consider establishing a group of key stakeholders to

provide a whole system approach to reviewing and revising local process to

ensure that the medicines required for end of life care can continue to be

available to those who need them, when they need them.

The exemplars from Health Boards included in this toolkit will need adaption and

agreement for local implementation in line with local Health Board clinical

governance processes. Consideration should also be given to any additional

training required to support health and social care professionals in undertaking

any new or extended roles.

In view of concerns around medicines shortages during COVID-19, Health Boards

will also want to support national and local approaches to maintaining the supply

chain of palliative care medicines, discouraging the over-ordering of these

medicines and minimising the waste of relevant medicines.

Summary

This palliative care toolkit provides health and social care planners and healthcare

professionals with a range of options and tools to help them to identify

appropriate and effective measures to improve access to supportive and palliative

care medicines across different health and social care settings.


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Section one: COVID-19 Contingency Plan – Scottish Palliative Care Pharmacy Association

Summary

There are a number of people who are at a higher risk of developing severe illness with COVID-19, including people who are aged

70 years or older (regardless of medical conditions) and people under 70 years of age with an underlying health condition,

including those given the flu vaccination each year on medical grounds. The COVID-19 response has raised a number of concerns

about the availability of both supportive and palliative care medicines across all care settings, and in particular those in care

homes and their own homes. Some of the concerns raised apply to all dying patients and not just those affected by COVID-19.

The following contingency plan outlines a range of actions, some of which have already been completed at a national level and

others which are for local consideration. The Scottish Palliative Care Pharmacy Association (SPCPA) have a key role in

development and implementation of these actions.

Priority area Solution Action by Timescale

1. Access to

palliative care

medicines –

primary and

secondary care

settings

Palliative Care Community Pharmacies and Community

Pharmacies

Each Health Board will have local arrangements for

the prescribing, supply and administration of

palliative care medicines.

Consider stock of Just in Case Box (JICB) medicines

Add stock of alternative palliative care medicines as

per national guidance.

Consider palliative care medicine stock levels in

community pharmacies that supply to care homes.

Local arrangements by

SPCPA members/each Health

Board/primary and

secondary care teams

As soon as

possible

(ASAP)


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Acute services

Consider stock of palliative care medicines as

required.

List of medicines on the COVID-19 end of life care

and alternative palliative care medicines emailed to

stores/distribution.

GP bags

Ask GPs to consider the stock of JICB medicines in

the GP bag.

Out of Hours (OOH) services

Consider stock in in OOH centres.

Hospice

Consider stock of essential palliative care

medicines. Consider strengthening local prescribing.

Consider arrangements in the community, including

the use of non-medical and HBP prescriptions.

Consider the use of a ‘Hospice palliative care bag’

for Hospice medical staff to administer to

community patients.

Any additional holding sites for palliative care

medicines needed e.g. COVID-19 Assessment Centres

Consider stock holdings.

2. COVID-19

education and

training

required

Two national COVID-19 palliative care guidelines ‘End

of life care guidance in COVID-19 patients’ and

‘Alternatives to regular medication normally given via

a syringe pump when this is not available’ have been

published.

SPCPA Complete


11

Guidelines available at

https://www.palliativecareguidelines.scot.nhs.uk.

Palliative care training resources available on Turas.

NHS Education for Scotland (NES) have circulated

palliative care training available with the 2 national

guidelines.

NES Complete

Training delivered locally. Local arrangement ASAP

3. Shortage of

essential

palliative care

medicines

Alternative palliative care medicine guideline written.

Ensure stock of these medicines.

Local arrangement ASAP

SPCPA, working with National Procurement (NP), will

continue to provide information on medicines

shortages and recommend alternatives.

SPCPA/NP/ current board

approach

Ongoing

List of medicines included in both national palliative

care guidelines emailed to NP.

SPCPA Complete

Consideration is being given at a UK level to the

repurposing of medicines in care homes and hospices

NHS England and the

Devolved Administrations

Ongoing

Consider approaches to reducing waste.

Some health boards reducing quantity of JICB

medicines prescribed (for example 5 amps rather

than 10).

Raise awareness of the potential shortages in all

settings to discourage over-ordering and minimise

waste of palliative care medicines

Local

arrangement/SPCPA/primary

care team

ASAP

Minimise waste of critical injectable medicines.

Guidance available from Specialist Pharmacy Services.


4. COVID-19

ACP

COVID-19 Anticipatory Care Planning (ACP) being

developed in all areas.



https://www.sps.nhs.uk/articles/minimising-wastage-of-critical-medicines-during-covid-19-2/


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5. Discharging

COVID-19

palliative care

patients home

from

Emergency

Departments

(ED)

National approach agreed.

Three key oral medicines (morphine 10mg/5ml liquid,

lorazepam and paracetamol) to be given as TTOs to

alleviate symptoms until a JICB/syringe pump/district

nurse is available where appropriate.

Healthcare Improvement

Scotland (HIS)/ SPCPA/

National Acute Pharmacy

Group Scotland

Complete

6. JICB

prescription

charts

Ensure extra supply of JICB medicine charts. Local arrangement ASAP

Extra to be distributed to the Hospice, Acute/ED, care

homes and community settings.

7. Care homes There are several approaches that can be taken

including:

strengthening the primary care prescribing

pathway.

use of extended home remedies.

use of protocols under regulation 247 of the

Human Medicines Regulations 2012 to support

supply and administration of medicines.

prescribing of ‘just in case’ boxes in anticipation.

NHS GG & C has produced a COVID-19 Strategy for

Palliative Care Drug Provision in Care Homes with

associated protocols. Health Boards considering the

use of protocols should seek advice from CLO.

Local arrangements ASAP

8. Not enough

district nurses

Most Health Boards have their own ‘informal carers

administering s/c medicines’ policy.

Local arrangement Complete

https://www.palliativecareggc.org.uk/?page_id=2370


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to administer

subcutaneous

(s/c) medicines

A national policy for ‘carers in care homes to

administer s/c medicines’ is being explored.

NHS Tayside ASAP

A video demonstrating s/c medicine administration has

been developed by Strathcarron Hospice for national

use. Available here.

Strathcarron Hospice Complete

Consider if s/c training is required for any members of

the palliative care team/Hospice medical staff.


9. Shortage of

syringe pumps

National procurement recently undertook a bulk

purchase of syringe pumps to help ensure that this

equipment remains available.

An initial supply of pumps has been released to boards

with further pumps being released over the coming

weeks, based on need.

Local arrangements. ASAP

10. Palliative

care Patient

Group Direction

(PGD)

Palliative care PGDs can be considered to support

timely access to palliative care medicines for symptom

control.


11. Shortage of

prescribers

Identify all non-medical prescribers that could

prescribe JICB medicines/palliative care medicines.


Consider adoption of a Health Board policy to support

prescribing dose ranges. This could allow patients

timely access to the appropriate dose and reduce the

number of calls to a prescriber to increase doses.

.


12. Single Nurse

Administration

(SNA) of

All Hospices currently use SNA.

Consider adoption of a Health Board policy for SNA of

controlled drugs

Local arrangement Ongoing



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controlled

drugs

13. Reducing

risk/governance

SPCPA hold a risk register for the national work.

All SPCPA members encouraged to complete a risk

register on an individual basis, for personal use.

SPCPA Ongoing

14. SPCPA

members

support

Weekly zoom meetings scheduled for support.

Make contact with any SPCPA member if struggling.

If SPCPA member is off - Any pharmacist/technician

can be added to the SPCPA email distribution list or

WhatsApp group, if urgent palliative care advice is

needed.

SPCPA members Ongoing


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Section two - Strengthening Primary Care

In Hours

Access to Medicines

There are risks associated with the global medicines supply chain of medicines,

both in the short and medium term. The Department for Health and Social Care

(DHSC) has asked NHS England (NHSE) to lead, on behalf of the UK, on sourcing as

much of the affected medicines as possible. National Procurement is working

closely with colleagues in NHSE to reinforce the supply chain for palliative care

medicines, as well as other supportive and critical care medicines.

Health Boards are asked to support the national approach to managing the supply

chain of palliative care medicines. Locally, there is also a need for measures which

discourage over-ordering of medicines and minimise waste. Health Boards should

consider the following steps:

• strengthening the current prescribing pathway by considering the

management of stock holdings of palliative care medicines across the

community pharmacy palliative care network, in GP practices, COVID-19

assessment centres, hospices and at community hospitals. For the COVID-

19 assessment centres, Health Boards may choose to mirror the

arrangements described under the Emergency Department section;

restricting the supply of ‘just in case’ boxes (JICBs) by improving

mechanisms to allow just in time dispensing of JICBs to preserve the stock

of critical medicines and reduce any unnecessary waste;

reducing, if appropriate, the quantity of anticipatory palliative care

medicines prescribed from ten to five ampoules or less;

minimising the waste of other critical injectable medicines based on the

guidance from Specialist Pharmacy Services.

supplying a ten day rather than a seven day supply of any subcutaneous

infusion medicines at discharge from secondary care to relieve the pressure

on the primary care teams; if appropriate.

strengthening arrangements for hospital pharmacy departments to support

community pharmacies in accessing critical medicines that are in short

supply; and

considering the use of:

o the prescribing of dose ranges in COVID-19 palliative care patients

taking account of the risks and benefits (Appendix A).

o the use of a single nurse administration policy (Appendix B).

https://www.sps.nhs.uk/articles/minimising-wastage-of-critical-medicines-during-covid-19-2/


16

o the SPOT clinical decision prescribing support tool (Appendix C);

o prescribing flow diagram for symptom management adapted from the

Scottish Palliative Care temporary guidelines for symptom

management for when a person is imminently dying from COVID-19

(Appendix D);

o pre-filled district nurse drug administration charts, MAR charts and

Communication Sheets (Appendices E, F and G);

o a JICB prescribing template (Appendix H).

Syringe drivers

Portable infusion pumps are normally used in palliative care to deliver a

continuous subcutaneous infusion of medication over 24 hours. Some acute areas

also use non-ambulatory pumps. Health Boards will want to ensure healthcare

professional know which device(s) are available for use and the current local

protocols for setting up and monitoring the syringe pump that is being used.

National Procurement has procured additional supplies of syringe pumps

however, Health Boards will also want to ensure that they have local strategies to

address circumstances when syringe pumps or associated consumables may not

be available.

Other measures

Alongside the legislative flexibilities described in the Executive Summary, there

are some legislative changes to the Misuse of Drugs Regulations 2001 that are

currently being considered at a UK level and which may become available during

the COVID-19 pandemic that will support the emergency supply of controlled

drugs from community pharmacies in certain circumstances. In addition, NHS

England is also considering the repurposing of previously dispensed but unused

medicines from Care Homes and Hospices and NHS Scotland will consider the

outcome of this work when it is available.

Out-of-hours

Health Boards should consider strengthening the current prescribing pathway by

considering the stock holdings in out-of-hours locations. This could include

increasing the availability of JICBs and/or the TTO packs of oral palliative care

medicines developed for the Emergency Department section. Community

pharmacists can accept a faxed or emailed prescription for Prescription Only

Medicines (POMs), but not controlled drugs from Schedules 1, 2 and 3, with the

exception of phenobarbitone or phenobarbital sodium for the treatment of

epilepsy, as long as it is followed up within 72 hours with a signed



17

prescription. Regulation 214 of the Human Medicines Regulations 2012 requires

that POMs are supplied in accordance with a prescription, however there is an

exception in regulation 224 which reflects the 72 hour requirement. This allows a

POM to be supplied where it has been “requested by a relevant prescriber who by

reason of an emergency is unable to provide a prescription immediately” and is

followed up with a prescription within 72 hours. An out-of-hours request for

either an acute or a repeat prescription would meet the definition under the

“urgent or emergency” criterion.


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Section three - Accessing oral palliative care medicines from Emergency Departments during COVID-19


19

Accessing palliative care medicines from Emergency Departments during COVID-19 for palliative care patients that are still able to take medicines orally

Summary

Generally, a palliative care patient, who wishes to die at home, or in a homely

setting, is prescribed ‘just in case’ box (JICB) medicines as part of the normal

discharge process from hospital. In order to complement this, and in situations

where the patient is not dying imminently, a range of alternative palliative care

medicines for oral use have been agreed and ‘To Take Out’ (TTO) packs will be

provided by NHS Scotland Pharmaceutical Specials Service (NHS PSS). This will

support a quick discharge home and allow a carer or relative to administer oral

medicines to help alleviate symptoms. Supplying these medicines may also

provide a bridge to a JICB which can be arranged in the community, as and when

required. In addition, to support this approach there are three Patient Group

Direction (PGD) templates (appendices I-K) for local adoption to facilitate the

supply of the TTO medicines and a Patient Information Leaflet (PIL) (Appendix L)

for supply with the TTO packs.

The flow chart at the start of this section may provide a protocol in the ED setting

for Health Boards to adapt for their use.

Background

The Scottish Palliative Care guidelines is the key source of information on the

management of adults with life limiting illness and is available at:

https://www.palliativecareguidelines.scot.nhs.uk. To complement the standard

end of life care guidelines, two temporary guidelines have been developed for

symptom management in the context of:

End of life care guidance when a person is imminently dying from COVID-19

lung disease

This guideline describes the symptoms of COVID-19 and the palliative care

medicines prescribed to help alleviate symptoms, at end of life. It was developed

using COVID-19 information from Scotland, worldwide and a consensus of

palliative care professional expertise across Scotland.

Alternative to regular medication normally given via a syringe pump when this

is not available

This guideline describes alternative palliative care medicines that that could be

prescribed in a crisis where there is a shortage of essential palliative care

medicines, syringe pumps or district nurses in the community to administer







20

subcutaneous (s/c) medicines. These medicines could, if appropriate, be

administered by a relative or carer.

Generally, palliative care patients discharged home for end of life care, are

prescribed ‘Just in case box’ (JICB) medicines as recommended in the Scottish

Palliative Care guidelines.

For palliative care patients that are imminently dying, and wish to die at home,

JICB medicines should be prescribed via the normal discharge process. However,

if the patient is not imminently dying and the patient wishes to return to a

homely setting then a range of alternative palliative care medicines for oral use

have been agreed by the Scottish Palliative Care Pharmacy Association (SPCPA)

and COVID-19 Palliative Guidelines Development Group. This will allow a quick

discharge home and allow the carer/relative to administer oral medicines to help

alleviate symptoms. Supplying these medicines may also provide a bridge to JICB

which can be arranged in the community, when required.

To assist in the management of patients who require palliative care at this time an

option is described on the supply of alternative medicines to help control patient

symptoms. This option for the supply of medicines at Emergency Departments

(EDs) has been developed considering the following factors:

Palliative care patients approaching end of life and still able to take oral

medicines

Arrangements for JICB cannot be accessed in a timely way to support

discharge of the individual

The medicines to be provided are oral medicines providing ease of

administration to patients by their carers

The medicines aim to help alleviate symptoms at end of life

Supply of these medicines will give ease of access to symptom relief and

may provide a bridge to the availability of JICB, where appropriate

Treatments described in this document are for adults (aged 16 years and

older)

This option help to ensure palliative care medicines are available to help alleviate

symptoms for end of life care, allowing individuals to be given access if required,

without unnecessary delay to manage the predictable and distressing symptoms

that can occur.


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Medicines

Medicine Symptom Dose Quantity to be

supplied

paracetamol

500mg

tablets/caplets

/ soluble

tablets

Pain/fever 500mg-1g (1 or 2)

tablets to be taken

every 4 to 6 hours.

Maximum 4g (8 tablets)

in 24 hours

32

tablets/caplets

Or

24 soluble

tablets

morphine

10mg/5mL

oral solution

Pain/breathlessn

ess/cough

2mg (1mL) to be taken

every 1 to 2 hours

when required

Maximum of 3 doses in

4 hours and 6 doses in

24 hours

1 x100mL

lorazepam

1mg tablets

(Genus, PVL or

Teva brands) –

tablets should

be scored and

blue in colour

Anxiety/distress

500 micrograms (half a

tablet) to be taken

sublingually every 4

hours when required.

Maximum of 4 doses in

24 hours.

10

In addition to this, where lorazepam is unavailable, then diazepam may be used as

an alternative. Dose information can be found in the Scottish Palliative Care

Guidelines: Alternative to regular medication normally given via a syringe pump

when this is not available.

Hyoscine hydrobromide patches may be supplied if secretions are problematic as

per the COVID-19 guidelines.

Where a prescriber chooses to give alternative medicines to the TTO packs

available then these should be prescribed and supplied as per normal discharge

medicines.

The medicines and dose have been reviewed and agreed by the SPCPA and

COVID-19 Palliative Guidelines Development Group.

https://www.nhsinform.scot/illnesses-and-conditions/infections-and-poisoning/coronavirus-covid-19/coronavirus-covid-19-general-advice#common-questions



22

Pre-packing of stock

NHS PSS are facilitating the availability of pre-packs for the three medicines

described above. Details for ordering of stock will be communicated as soon as

they are available.

In the interim, arrangements for the local over labelling and pack down may need

to be put in place for supply into the local EDs.

Health Boards will be aware of the following interim advice:

As discussed at the Scottish Unlicensed Medicines Advisory Board (SUMAB) given

the current position it would be prudent to allow relaxation of the rules around

the number of packs which can be over labelled/packing down provided there are

safe systems of work in place, please refer to the attached guidance document for

recommendations on the systems that should be in place.

SPQAG

Repackaging overlabelling guidance Version 2 May 2019 (2).pdf

Supply at Emergency Departments

Prescriptions for these medicines would be generated by prescribers in EDs using

local systems e.g. admission card/document, HEPMA protocols. In line with a

prescription the patient/carer will be provided with TTO supplies of the medicines

and the medicines supplied should be recorded following usual processes.

Information on the medicines prescribed should be included in any discharge

communication to GPs/primary care as per usual practice stating the medicines

that have been provided. The Key Information Summary (KIS) can be accessed in

EDs. A COVID-19 Anticipatory Care Plan is available as a word document which

can be completed or updated and sent to GP practices to be copied into KIS as

required. A digital service with electronic form is planned to be available shortly.

Further information on Anticipatory Care Planning can been found here.

A patient/carer information leaflet (Appendix L) providing information on the

medicines supplied should be provided to the patient/carer as well as advice on:

How to arrange further medicines if required

What to do if the condition changes or deteriorates further

What to do if admitted to hospital or another care setting

How to dispose of medicines that are no longer needed

https://www.rcgp.org.uk/covid-19/-/media/A49BF4DCAA304907B15B5F4E0B67BA33.ashx


23

Stock top up arrangements to EDs should follow local processes.

Patient follow up

Communication to allow timely patient follow up is essential. The usual

mechanisms for updating Primary Care on other medicines and/or clinical

decisions made at ED should be utilised to share information in relation to

medicines provided for palliative care. Local palliative care services should be

contacted for advice to ensure patient follow up.

Primary care teams should ensure patient follow up to provide re-assessment and

where necessary make arrangements for access to Just In Case Boxes via normal

routes as appropriate for the patient.

Accessing palliative care medicines from COVID-19 Assessment Centres when

access to the JICB arrangement is unavailable/inappropriate for adults

While this section focusses on supply arrangements from EDs, the same factors

can be taken into account when considering the options for the supply of

palliative care medicines from COVID-19 assessment centres.

The patient information leaflet relating to the medicines is also appropriate for

use within the assessment centre setting.

Mechanisms for the supply, prescribing, administration and stock top up of

palliative care medicines will need to be established in line with the local

processes to access other medicines for use at the centres. Likewise the standard

processes for communication of key patient information to the primary care

teams should be used to convey palliative care issues.

The PGD templates are included in Appendices I-K for paracetamol, morphine and

lorazepam for local adoption, as required, as a potential option to support patient

access in this setting.


24

Section four - Accessing palliative care medicines in care homes


25

Access to palliative care medicines for care home residents

during the COVID-19 pandemic

Summary

Health Boards may wish to consider the following approaches to strengthening

access to medicines in care home settings:

preparing anticipatory prescriptions for Just in Case Boxes (JICBs) for

residents which are only dispensed if needed for that individual

resident. These can be repeated every 28 days as necessary. This approach

will minimise the waste of specific medicines;

expanding the use of homely remedies to include a number of Pharmacy

Only (P) and General Sales List (GSL) medicines to provide symptomatic

relief;

using the To Take Out (TTO) packs of medicines that are being provided to

Emergency Departments (EDs) as a bridge to alleviate symptoms; and

making use of the supply and administration of certain Prescription Only

Medicine (POM) medicines under a specific protocol which has been

approved by a Health Board.

The flow chart at the start of this section provides a protocol for care home

settings for Health Boards to adapt for their use.

Introduction

The COVID-19 pandemic raises challenges for care home staff, their families and

the staff looking after them. Care home residents are particularly vulnerable to

COVID-19 as they are increasingly frail and elderly with complex co-morbidities.

The symptoms of COVID-19 can be aggressive and escalate quickly, therefore care

home residents will need quick access to palliative care medicines to help

alleviate symptoms and reduce suffering.

It is predicted that with the escalation of COVID-19, the healthcare system will be

under immense pressure which may result in a reduced number of carers and

healthcare professionals. In addition to this, it is anticipated that there may be a

shortage of essential palliative care medicines and syringe pumps. This guideline

describes how care home residents can access palliative care medicines

throughout the COVID-19 pandemic.


26

Care Homes

There are over 35,000 residents in over 1,000 care homes in Scotland. There are

many different types of care home (care of the elderly, children, nursing,

residential etc.) that are managed by the NHS, local authority, voluntary or private

organisations. All these residents access care through the carers, their GP,

pharmacists, nursing staff (either on site nursing or district nurses) and other

healthcare professionals. Appendix M provides a visual that captures the wide

range of activities that should be considered as part of a package of care to care

home residents in the context of COVID-19. There is also a video explaining the

visual available here.

The recent guidance from the British Geriatrics Society ‘Managing the COVID-19

pandemic in care homes’ states that ‘care homes should work with GPs and local

pharmacists to ensure that they have a stock of anticipatory medications and the

community prescription chart, to enable, at short notice, palliative care for

residents’.

Current process for care home residents accessing palliative medicines

Currently, GPs prescribe JICB medicines (morphine, midazolam, hyoscine

butylbromide and levomepromazine ampoules), on an individual patient basis, to

help alleviate symptoms, at the end of life. These medicines are prescribed in

advance of symptoms, so they are available when required. With the escalation

of COVID-19, this approach has the potential to result in a very large volume of

JICB medicines being prescribed for care home residents. While it is essential that

care home residents have access to this medication, it is likely that many of these

individually prescribed medicines will not be used and this will result in the

potential waste of medication that may be in short supply.

JICB medicines are administered subcutaneously, therefore are currently

administered by nursing staff.

Anticipated problems accessing palliative care medicines during COVID-19

With the expected strain on the healthcare system and carers, there may be

delays in care home residents accessing palliative care medicines due to:

shortage of carers looking after care home residents;

shortage in prescribers to prescribe palliative care medicines;

medicine supply issues with essential palliative care medicines;

https://vimeo.com/404555153

https://www.bgs.org.uk/resources/covid-19-managing-the-covid-19-pandemic-in-care-homes

https://www.bgs.org.uk/resources/covid-19-managing-the-covid-19-pandemic-in-care-homes


27

delays in dispensing medicines in Community Pharmacy due to staff

shortages (potential for pharmacy closures), increased workload and

medicine supply issues; and

limited nursing staff available to review residents and administer

subcutaneous medicines.

Supporting access to palliative care medicines for care home residents

Ways to support care home residents accessing palliative care medicines include:

Shortage of GPs/prescribers to prescribe the palliative care medicines.

In the event of limited access to GPs to prescribe palliative care medicines, ways

to support this are:

allowing dose ranges to be prescribed, to allow effective titration of

palliative care medicines, to reduce suffering, for resident’s experiencing

severe COVID-19 symptoms. This is described in detail in Appendix A;

identifying other non-medical prescribers (for example advanced nurse

practitioners (ANP’s), independent pharmacist prescribers etc.) who could

prescribe these medicines; and

distribution of JICB kardexes to all care homes so they are available for

immediate access, if required.

Access to palliative care medicines

Care home residents can access palliative care medicines via the:

Homely remedy policy

Many care homes have a homely remedy medicines policy. This allows care

homes to stock medicines for minor ailments such as paracetamol for pain, senna

for constipation and simple linctus for cough. Such homely remedy policies can be

updated to include other General Sales List (GSL) and Pharmacy (P) medicines that

may provide relief of the COVID-19 symptoms. For example:

P or GSL palliative care medicine COVID-19 symptom

Paracetamol tablets/liquid/suppositories Pain, fever

Codeine linctus 15mg/5mL liquid Cough

Prochlorperazine 3mg buccal tablets Nausea and vomiting

Hyoscine hydrobromide 300mcg tablet Respiratory secretions

Hyoscine 1.5mg patches Respiratory secretions

All these medicines are listed in the temporary palliative care guideline

‘Alternatives to regular medication normally given via a syringe pump when this



28

is not available’ and would enable a carer to administer these medicines, to help

alleviate symptoms and reducing suffering, until the resident could be reviewed

by a health care professional.

Community Pharmacy

Generally, care home residents access medicines through community pharmacy.

They are not currently eligible for the Minor Ailment Service. Care home

residents can obtain alternative palliative care medicines, via a GP10 prescription,

which a carer can then administer. For example, a patient in pain, who is opioid

naïve, can be prescribed morphine sulfate oral solution and/or a buprenorphine

patch, rather than a morphine syringe pump, which needs to be administered by a

nurse on a daily basis. This empowers the carer to administer medicines to help

relieve symptoms and allows the nursing team to be able to prioritise patients

and focus on the residents who remain symptomatic. Details of alternative

medicines that can be prescribed are described in the national palliative care

guideline ‘Alternatives to regular medication normally given via a syringe pump

when this is not available’, available at

https://www.palliativecareguidelines.scot.nhs.uk/. These are also listed in

Appendix O.

Anticipatory prescribing JICB medicines

All JICB medicines are prescribed on an individual patient basis. This may result in

a significant volume JICB medicines being prescribed and subsequently wasted if

they are not used. This is a particular concern in the context of potential supply

challenges for palliative care medicines. Where COVID-19 is confirmed in a care

home, JICB medicines could be prescribed on a GP10 prescription but not

dispensed in community pharmacy until they are required – a form of delayed

prescribing. This could save on wastage, however, it will take some GP time to

prescribe all the individual JICB medicines. Some Health Boards are also reducing

the number of ampoules prescribed in a JICB to reduce wastage.

All palliative care medicines

A full list of all the palliative care medicines available, including how to access

them and who they can be administered by, is listed in Appendix N which outlines

an approach based on a Model of Care developed by NHSGG&C. This provides

clarity on which palliative care medicines can be administered by a carer. This

empowers carers to help relieve symptoms and allows nursing staff to prioritise

patients, who remain symptomatic.




29

Advice on managing symptoms in palliative care is available on the Scottish

Palliative Care guidelines website.

Two temporary palliative guidelines on caring for palliative care patients dying of

COVID-19, ‘End of life care when a person is imminently dying from COVID-19

lung disease’ and ‘Alternatives to regular medication normally given via a syringe

pump when this is not available’ are available at

https://www.palliativecareguidelines.scot.nhs.uk/.

Care Homes holding stocks of POMs

In the event of a pandemic, there are options to allow the supply of POMs to

patients within the existing legislative provisions in the Human Medicines

Regulations 2012. As described in the Executive Summary, the 2012 Regulations

set out various exemptions to regulation 214 which specifies that a person may

not supply a POM except in accordance with a prescription given by an

appropriate practitioner. For example, regulation 247 allows the supply of a POM

without a prescription in a pandemic situation, provided certain conditions are

met. These conditions include that the supply must be made whilst a disease is, or

in anticipation of a disease being imminently pandemic and a serious risk, or

potentially serious risk to human health. It must also be made under a disease

specific protocol which must be approved by UK Ministers or an NHS body. “NHS

body” includes territorial Health Boards in Scotland. The protocol must specify the

symptoms of and the treatment of that disease. Any Health Board considering

putting a protocol in place which relates to the supply of medicines in care homes

will want to satisfy themselves that any protocol complies with regulation 247 of

the Human Medicine Regulation 2012 as well as the legislation which sets out the

requirements for controlled drugs, for example the Misuse of Drugs Regulations

2001. The Central Legal Office (CLO) will be able to provide Health Boards with

advice on this.

This type of approach would allow a care home to stock medicines such as:

Medicine Symptom of COVID-19

Hyoscine Butylbromide 20mg/mL amps Respiratory secretions

Levomepromazine 25mg/mL amps Agitation/delirium

Haloperidol 5mg/mL amps – second line Agitation/delirium

This supports timely access to palliative care medicines, to help alleviate

symptoms, for end of life care. NHS Greater Glasgow & Clyde (GGC) have adopted

this approach and their COVID 19 Palliative Care Medicines Policy for Care Homes

can be found here, This provides an example of one Health Board’s approach








30

using the pandemic exemption in Regulation 247 of the Human Medicines

Regulations 2012.

In line with the NHSGGC protocol, relevant Prescription Only Medicines are pre-

authorised by a prescriber for individual patients. In the event of symptoms

arising, a nurse is required to discuss the patient’s symptoms and confirm their

care plan with a prescriber before the medicine is administered for 48 hours.

Thereafter a regular prescription is required to support ongoing treatment.

Any Health Board using the pandemic flexibilities pandemic to allow the supply of

POMs to patients within the existing legislative provisions in the Human

Medicines Regulations 2012 will need to ensure that they have an exit strategy

from those arrangements when the pandemic status is withdrawn.

Shortage of essential palliative care medicines

Palliative care medicine shortage advice

It is anticipated that there will be shortages of essential palliative care medicines,

due to the increase in demand. Currently, community pharmacists and local Health

Board arrangements provide advice on medicine supply issues and palliative care

pharmacists recommend alternative medicines, for symptom control.

Re-using care home residents JICB medicines

If a resident’s JICB medicines are not used and they die, it is current practice to

destroy these medicines. This may result in the destruction of many JICB

medicines that have been dispensed for individual residents. There is work being

considered at a UK level on the repurposing of certain medicines from care homes

and hospices and NHS Scotland will consider this work and its practical application

when it becomes available.

Conclusion

This section describes different options to support timely access to palliative care

medicines for care home residents, despite the potential challenges presented by

COVID-19. Appendix O provides a summary of all issues to be considered and

potential approaches.




31

Appendix A: Prescribing dose ranges for COVID-19 palliative care patients during the pandemic

Situation

The symptoms of COVID-19 can be aggressive and escalate quickly, therefore

palliative care patients need quick access to palliative care medicines, to help

alleviate symptoms and reduce suffering. It is predicted that with the escalation

of COVID-19, the healthcare system will be put under immense pressure which

may result in a reduced number of healthcare professionals. This appendix

outlines an approach to the prescribing of dose ranges in COVID-19 palliative care

patients and outlines the risks and benefits of such an approach.

Background

The standard palliative care medicines, ‘Just in case box’ (JICB) medicines

(morphine, midazolam, hyoscine butylbromide and levomepromazine amps), as

recommended in the Scottish Palliative Care guidelines, are prescribed to help

alleviate symptoms at the end of life. These medicines are prescribed in advance

of expected symptoms developing and the doses are correspondingly low.

A national palliative care guideline, ‘End of life care guidance when a person is

imminently dying from COVID-19 lung disease’ has been developed, using COVID-

19 information from Scotland, worldwide and a consensus of palliative care

professional expertise across Scotland. This guideline describes higher doses of

standard palliative care medicines that may be required to control the COVID-19

symptoms, experienced at the very end of life.

Therefore, a palliative care patient suffering from COVID-19 symptoms, may

require higher doses than those prescribed on a standard JICB Kardex, to control

their symptoms. Fixed dose prescribing would therefore result in a call to the

prescriber to authorise an increase in dose. This takes time and delays the patient

receiving the most appropriate dose, to control symptoms.

Assessment

The legal and professional guidance on dose ranges is set out as follows, with the

associated advantages and disadvantages.

British National Formulary

Prescribing dose ranges is legally acceptable, and this is detailed in the British

National Formulary (BNF) and the palliative care formulary. However, the

guidance is very clear that dose ranges are only legally acceptable when part of

an instruction to administer. In the prescription writing requirements in the BNF,

it states that ‘Use of decimal points is acceptable to express a range’.




https://www.bnf.org/

https://www.bnf.org/


32

Misuse of Drugs Regulations 2001

Under the Misuse of Drugs Regulations 2001, Regulation 7 describes the

administration of drugs in Schedules 2, 3, 4 and 5

(1) Any person may administer to another any drug specified in Schedule 5.

(2) A doctor or dentist may administer to a patient any drug specified in Schedule

2, 3 or 4.

(3) Any person other than a doctor or dentist may administer to a patient, in

accordance with the directions of a doctor or dentist, any drug specified in

Schedule 2, 3 or 4.

Home Office

Previous correspondence from the Home Office in 2011* stated:

‘Where an instruction to administer is given the prescriber has flexibility

to instruct a range of doses to be used’.

‘Where a dose range is prescribed it should be suitable for the patient's

condition and previous opioid use and should not be sufficiently wide to

allow overdose to occur’.

Nursing and Midwifery Council (NMC) standards

Previously Standard 13 from the NM standards for Medicines Management stated,

"Where medication has been prescribed within a range of dosages it is acceptable

for registrants to titrate dosages according to patient response and symptom

control, and to administer within the prescribed range”.

Whilst these standards have been withdrawn, they contain useful detailed

guidance which is often referred back to support the current professional

overview guidance.

Royal College of Nursing (RCN) and Royal Pharmaceutical Society (RPS)

Dose ranging is not specifically mentioned in the RCN/RPS Professional guidance

on the administration of medicines in healthcare settings (2019).

Palliative Care Formulary

Prescribing a range of permitted dose ranges allows nurses to increase the

amount given on their own initiative. In practice, nurses tend to start with the

lower dose, but increase to the top of the range if necessary.

Advantages of prescribing dose ranges for COVID-19 palliative care patients

The potential advantages of prescribing dose ranges are that they:

enable a nurse to use their professional judgement to administer the most

appropriate dose, to alleviate symptoms and reduce suffering;

support timely access to the patient receiving the most appropriate dose to

alleviate symptoms, especially as symptoms can escalate quickly;


https://www.rpharms.com/Portals/0/RPS%20document%20library/Open%20access/Professional%20standards/SSHM%20and%20Admin/Admin%20of%20Meds%20prof%20guidance.pdf?ver=2019-01-23-145026-567

https://www.rpharms.com/Portals/0/RPS%20document%20library/Open%20access/Professional%20standards/SSHM%20and%20Admin/Admin%20of%20Meds%20prof%20guidance.pdf?ver=2019-01-23-145026-567

http://www.palliativedrugs.com/


33

reassure the family that if symptoms don’t settle, then further medication

doses can be administered safely;

may be beneficial if there is a shortage of syringe pumps and symptoms

need to be controlled with subcutaneous ‘as required’ medicines; and

reduce the number of calls to the GP/OOH/prescriber to increase doses.

Disadvantages of prescribing dose ranges for COVID-19 palliative care patients

The potential disadvantages of prescribing dose ranges are that an inexperienced

nurse administering an inappropriately high dose for a patient resulting in patient

harm.

Ways to reduce the risk of patient harm

Only allow a small range (for example 2mg to 5mg of morphine, midazolam)

for prescribing dose ranges.

Write both doses in full (for example 2mg to 5mg rather than 2-5mg) to

minimise the risk of misreading (2-5mg could be misread as 25mg).

If the nurse hasn’t any knowledge of the previous response to the drug, the

lowest dose within the range should be used.

Where knowledge of previous response suggests that an increase in dose

may be required the nurse would need to judge the risks of potential

adverse effects against the potential to gain symptom relief.

Where prior response is unknown or where new clinical factors require

consideration, starting at higher doses within the range prescribed would

normally be implemented only after consultation with an experienced

colleague, prescriber or member of the specialist palliative care team.

There will be maximum number of doses permitted in a specific time frame,

following which a prescriber needs to be contacted.

If the highest dose within the range has been administered, and the patient

is still suffering from symptoms a doctor/experienced nurse needs to be

contacted

Safeguarding approaches

The medicine will already be prescribed by a prescriber that has clinically

assessed the patient and there are no contraindications.

Prescribing dose ranges is only suitable for medicines for which the

prescriber considers there is a clinical indication.

Only a small dose range (for example 2mg to 5mg) is allowed.

Information will be provided by the prescriber detailing when a higher dose

(within the dose range) can be given

A maximum number of doses per 24 hours must be stated.

Good communication between the prescriber and nurse is essential.

It must be clear to the nurse when medical advice must be obtained (for

example, when a second dose, from top of the range, has been given).


34

Recommendation

Some health boards, particularly in remote and rural areas, for example NHS

Highland, have supported the prescribing of dose ranges since 2011. This

approach can be used nationally to reduce the pressure on prescribers, allow

nursing staff to use their professional judgement to administer the most

appropriate dose to care for the patient and most importantly, support the patient

to receive timely access to medicines, to reduce suffering.

Any Health Board wanting to support the prescribing of dose ranges, will want to

consider gaining agreement for implementation in line with local Health Board

clinical governance processes and local guidance will need to be widely

communicated to all members of the healthcare professionals involved (doctors,

nurses and pharmacists) to highlight the change in practice.

*Correspondence from Jane Smith. Principal Pharmacist Medicines Management. Home Office 2011.


35

Appendix B: Single Nurse Administration (SNA) of Controlled Drugs

Situation

With impending widespread staff shortages, the current process of dual nurse

(person) administration and checking of some medicines has the potential to

impact on service delivery, symptom management and patient care.

Background

A brief review of policies from different settings has identified that there is mixed

practice both across and within settings within respect to single and dual nurse

(person) administration of CDs.

Hospice setting

SNA is undertaken by nurses in majority of hospices in Scotland. Those hospices

which have not adopted SNA are NHS facilities following local hospital/acute

policies. Rigorous nurse training involves self-assessment as well as assessment

and supervision by other healthcare professionals. The time required for training

varies between hospices but it has been reported that for some staff, the training

can be undertaken in a single shift. The time required is dependent on the level of

experience of individual nurses.

Acute setting

In the acute setting it would appear that the administration of CDs (including

recording in CD Register) is routinely undertaken by two nurses. Only

exceptionally is SNA current practice where a risk assessment has been

undertaken. The administration of other oral medicines and IV medicines may be

carried out by one nurse with necessary calculations being checked by an

additional healthcare professional where practicable.

It is noted that SNA of CDs by district nurses is standard practice in the

community setting. However administration is undertaken in line with patient

specific directives using patient’s own stock from a community pharmacy.

Prison setting

Nurses, healthcare assistants or pharmacy assistants are employed to administer

the majority of medicines which are supplied as individually named patient items.

However, 500 items per week are supplied to prisons as stock items, including

methadone, opioid substitution therapy and diazepam and dihydrocodeine for

safe management of withdrawal. Two people, one of whom is always a nurse, are

required to sign CDs out of the CD register and these two people then undertake

administration of the CDs (generally methadone and buprenorphine).


36

Assessment

Legislative position

Royal Pharmaceutical Society/Royal College of Nursing Guidance

The current RPS/RCN Professional Guidance on the Administration of Medicines in

Healthcare Settings, aimed at registered healthcare professionals administering

medicines, advises that ‘the organisation’s administration procedure is followed’.

The Guidance states ‘Risk assessments must be undertaken to inform

organisational policies/procedures for second signatories, witness requirements,

and delegating’ and also recommends that ‘any calculations are double checked

where practicable by a second person and uncertainties raised with the prescriber

or pharmacy professional’.

CEL 2008 (07)

CEL2008_07 is the main guiding legislation in Scotland and it provides a guide to

good practice in secondary care on the safer management of controlled drugs. It

requires healthcare practitioners to adhere to relevant local policies. It advises

that the healthcare organisation may wish to stipulate that receipt of CDs and

updating of the register should be witnessed by a second competent person.

Additionally the administration of CDs within secondary care should normally be

done via two-person administration process. Any departure from the double

check process should be considered exceptional and carry with it a specific risk

assessment to support this practice

In summary, it would appear that there is no legislative barrier to SNA of CDs if

local policies can be updated to support the change. A risk assessment is required

for individual settings before this practice could be adopted to minimise the risk

of error and/or criminal activities which could have significant consequences for

patients, staff and the healthcare organisation.

Minimising any associated risk

Factors to be considered before adoption of SNA for CDs are set out in the

following table.

Factor Comment

Legislative requirements

for

records in CD register

safe custody

Only need to record schedule 2 CDs (recording of

Schedule 3 CDs is custom and practice in some

settings)

The nurse administering the CD must record the

activity in the CD register

Balance checks can be undertaken by a single

person (not necessarily a nurse)

Only schedule 2 CDs and a limited range of

schedule 3 CDs require safe custody

https://www.sehd.scot.nhs.uk/mels/CEL2008_07.pdf


37

Risk of misuse/theft

Fear of censure in the

event CDs go missing

CD register balance checks required for only for

schedule 2 CDs with the frequency depending on

risk assessment e.g. frequency of use and

previous CD related incidents

Regulatory bodies have advised that they are

adopting a supportive approach during the

current crisis

Clinical use An incremental approach with initial adoption of

SNA for CD doses/formulations that nurses are

experienced using in their specialist clinical

practice setting would be preferred. However it is

noted that higher initial doses of CDs are required

for the control of COVID-19 symptoms.

There may be specific circumstances 2 individuals

should still be involved and this need considered

as part of the appropriate risk assessment

Competence of nursing

staff

Training packages are available to support nurses

to increase competence and confidence whilst

ensuring that they remain within their scope of

practice

The Strathcarron Hospice has given permission

for their package to be used by all hospices.

The timing to introduce such a change in policy

and procedures is challenging in view of the

number of new and returning nurses moving into

clinical practice. However this change in practice

is only appropriate for those nurses that are

confident and competent to undertake SNA of

CDs.

Proposals for consideration

With reference to these factors it is proposed that SNA may be considered for a

limited time period subject to review as follows:

Hospice setting

In view of the current high level of experience of handling CDs, it is proposed that

further steps should be taken to explore rolling out SNA of CDs to the NHS

hospices. Use of established hospice training packs could empower those nurses

that can demonstrate their competence and have the confidence to work in this

way. This proposed change is supported by information from local hospice audits

which suggest no increase in error rate, post introduction of SNA procedures.

Acute settings

The resource required to supervise and assess the nurses in training is noted, but

training packages in hospices are readily available and could be shared and

adapted/adopted for use in acute settings.


38

Nurses currently working in high risk clinical areas such as critical care, high

dependency and coronary care units already operate with a degree of autonomy

and level of expertise in the administration of high risk medicines and may be

best placed to undertake SNA of CDs in the first instance. It is proposed that

further steps should be taken to explore the adoption of SNA of CDs in these

areas. Thereafter boards could consider roll out to other clinical areas e.g.

respiratory, A&E etc. Any potential resistance from nurses, managers and

pharmacy to adopt this change will need to be overcome to support

implementation.

Prison settings

The resource required to supervise and assess the nurses in training is noted but

it is proposed that SNA of CDs should be explored in the prison setting.

Recommendation

There are a range of circumstances where the use of singe nurse administration of

CDs may be possible in the hospice, acute and prison settings to alleviate

pressures.

Any Health Board wanting to support single nurse administration prescribing will

want to gain consensus agreement for implementation in line with local Health

Board clinical governance processes and local guidance will need to be widely

communicated to all members of the healthcare professionals involved (doctors,

nurses and pharmacists) to highlight the change in practice.


39

Appendix C: the SPOT clinical decision prescribing support tool

Situation

The COVID19 pandemic is creating an increased demand for opioids and leading to

a shortage of first-line opioids that are familiar to prescribers. This creates

uncertainty around opioid prescribing and conversion between one opioid or

route of administration and another to ensure equal potency and avoid the harms

associated with over- or under-dosing.

The solution is the Safer Prescription of Opioids Tool (SPOT). SPOT is a novel

Clinician Decision Support Digital Health CE-marked medical device. In a real

world, cross setting and multi-professional study1 across NHS Tayside, it is proven

to significantly improve the confidence of opioid prescribing in users and

adherence to best practice guidelines. SPOT has undergone large-scale testing in

an NHS Board and is now ready for national level deployment to support the

COVID pandemic.

Background

SPOT is designed to reduce unwarranted variation and primary and secondary

harms when prescribing opioids whilst supporting warranted variation of choice

to align to individual situations, values and side effect profiles. It supports

prescribers when their usual first line choice of opioid is not available or

inappropriate for the clinical situation.

SPOT was created and trialed in NHS Tayside over a four year period across

primary, secondary and tertiary care by a multi-professional interdisciplinary

team including independent prescribers, pharmacists, a clinical pharmacologist

and director of research, the RCGP Executive Officer (Quality Improvement), the

Palliative Medicine Special advisor to the Scottish Government Health & Social

care Directorate and the Chief Medical Officer and National Clinical Lead for

Palliative and End of Life Care for Health Improvement Scotland. Since July 2019,

SPOT has been used in day-to-day practice in NHS Borders.

1 https://doi.org/10.3390/ijerph16111926

https://doi.org/10.3390/ijerph16111926


40

SPOT enables clinicians to independently and remotely double-check their

equianalgesic opioid conversions safely, quickly and conveniently at the patient’s

bedside, whilst providing access to nationally adopted best-practice Scottish

Palliative Care Guidelines. This helps to reduce and mitigate risk, preventing

conversion errors leading to harm and increasing spread of opioid options for

each individual to have personalised analgesia approaches implemented.

Following an Innovate UK funded development programme, SPOT is ready for

deployment at scale. It is available in web-app, iOS and Android hybrid-app

format. SPOT has been assessed and meets the standards of the NHS Scotland

Quality Assurance Framework for Medical Device Apps, and is linked on

https://rightdecision.scot.nhs.uk. The Scottish Palliative Care Guideline Group and

Chair of this group have reviewed and endorsed SPOT.

At present there is currently no clinically validated opioid prescribing clinician

decision support tool available internationally.

Assessment

SPOT provides the following functionality:

• SPOT uses an algorithm based on the equianalgesic tables from best practice

guidelines.

• Conversion of equianalgesic doses of opioids, allowing simple conversion from

one opioid and route of administration to another. Independently validating

drug conversions, at the patient’s bedside.

• All drug preparations in the pharmacy are listed bespoke to each drug, aiding

drug selection.

• Links to gold-standard reference to inform prescribers.

• All conversions are auditable centrally, providing a clinical governance and

audit trail.

• SPOT promotes consistency of opioid conversion throughout whole system

through supporting individual clinical decisions, widening opioid repertoire for

individual clinicians and educates in real-time through both these

mechanisms.

The intended users are junior doctors, any trainee doctor/consultant prescribing

opiates in a palliative patient, pharmacists supporting safe prescribing in settings

with palliative patients, independent prescribers, GPs and GP trainees both in

hours and out of hours.

https://rightdecision.scot.nhs.uk/


41

Furthermore, research into SPOT has identified that not only is SPOT proven to

improve prescriber confidence when performing opioid conversion, but it has the

ability to improve prescriber performance.

Using machine learning, we have identified that when adopted at scale SPOT can

be used to simultaneously harness information that could help the development

of guidelines for pain management and also monitor prescriber performance to

ensure safe and effective treatment of pain. Not only this, but SPOT can identify

the magnitude of an error, whether that is likely to cause harm, and identify the

calculations that colleagues find most taxing.

The aim of SPOT is to support prescribers in using first, second and third line

opioids throughout the COVID19 pandemic and beyond into normal business-as-

usual practice.

Recommendation

SPOT is the only CE-Marked, clinically-validated equianalgesic opioid converter in

clinical practice, assessed against the NHS Scotland Quality Assurance Framework

for Medical Device Apps, based upon the Scottish Palliative Guidelines, proven to

improve adherence to guidelines and confidence in prescribers which is ready for

national-level adoption and is currently rolled out in an NHS Board. It is designed

to support prescribers during shortages associated with the COVD19 pandemic

and prescribers using unfamiliar opioids. It comes with the mandated software

support, updates, indemnity and ongoing clinical appraisal to continue to fulfil this

the National Assurance Framework.

Author of Report: Dr Deans Buchanan, Clinical Lead and. Consultant Palliative

Medicine, Palliative Medicine Special advisor to the Scottish Government Health &

Social care Directorate and the Chief Medical Officer and Dr Scott Jamieson,

Prescribing Lead, Angus HSCP

Updated 13/4/20 - Dr Roger Flint GP Registrar

Date: 13/04/20


42

Appendix D: Example of Guidance for Prescribing and Administering PRN medication when a Person is Imminently Dying from COVID-19 Lung disease


43

Appendix E: SAMPLE Drug Administration Instruction Chart (courtesy of NHS Tayside)

«PATIENT_Title»

«PATIENT_Forename1»

«PATIENT_Surname»

CHI: «PATIENT_CHI_Number»

«PATIENT_House»«PATIENT_Road»

«PATIENT_Town»

«PATIENT_Postcode»

DRUG ADMINSTRATION INSTRUCTION CHART (ADAPTED FOR ANTICIPATORY MEDICATION)

Sheet No : ______________

Date/Time Name of Drug Dose to be Administered

and Frequency

Method of

Administration

Prescribed By

(signature)

Date

Stopped

Stopped by

(Signature)

Date/Time Name of As Required

Drug

Dose to be Administered

and Frequency

Method of

Administration

Prescribed By

(Signature)

Date

Stopped

Stopped By

(Signature)

Morphine Sulfate

Injection 10mg/1ml

2 mg hourly as needed for

pain or breathlessness SC injection

Midazolam Injection

10mg/2ml

2 mg hourly as needed for SC injection


44

Patient Name: ………………………………………………………… CHI No: ………………………………………………….

«PATIENT_Title»

«PATIENT_Forename1»

«PATIENT_Surname»

CHI: «PATIENT_CHI_Number»

«PATIENT_House»«PATIENT_Road

» «PATIENT_Town»

«PATIENT_Postcode»

DRUG ADMINISTRATION

INSTRUCTION CHART

Sheet No ……..

Date/Time Name of Drug Dose to be

Administered

and Frequency

Method of

Administration

Prescribed By

(signature)

Date

Stopped

Stopped by

(Signature)

anxiety/ distress/

myoclonus

Hyoscine

Butylbromide

Injection 20mg/1ml

20 mg hourly as needed

(max 120mg/24hrs) for

respiratory secretions

SC injection

Levomepromazine

25mg/1ml injection

*.........mgs

*............hourly as needed

for nausea

SC injection


45

Date/Time Name of As

Required Drug

Dose to be

Administered and

Frequency

Method of

Administration

Prescribed By

(Signature)

Date

Stopped

Stopped By

(Signature)

Morphine

10mg/ml

injection

2mg every hour as

required for pain or

breathlessness

SC injection

Midazolam

10mg/2ml

injection

2mg hourly as

required for

anxiety, distress or

myoclonus

SC injection

Hyoscine

butylbromide

20mg/ml

20mg hourly as

required for

excessive

respiratory

secretions up to a

maximum of

120mg in 24 hours

SC injection

Haloperidol 5mg

/ml

0.5ml injected sc

every 12 hours for

nausea/ vomiting

as required

SC injection


46

Appendix F: SAMPLE Medication Administration Record Pharmacy Check

Patient/Client Name

CHI

Address

GP Practice Start Date End Date

Medication Name,

Strength, Form

Time Dose

C/F: Qty: Qty Rec: By: Date: Qty Ret: Date: By:



47





Please refer to their dispensed label for full medication instructions

Codes to be used if medication is not taken R: refused O: See Overleaf please see carer medication notes for detail

1 of X


48

Appendix G: SAMPLE Communications Sheet

Patient/Client Name

CHI

Address

Pharmacy Name Pharmacy Address Pharmacy Tel No

GP Practice

Start Date For New Prescription Cycle

Order Date

Medication Name Strength Form Directions Quantity

Required

Discontinued

By Prescriber

Changes To Directions

Continue

on MAR

Discontinue

on MAR

Pharmacy

Contacted

Initials


49

Appendix H: Example of Just in Case Box prescribing from NHS Tayside


50


51


52


53

Appendix I: Patient Group Direction (PGD) template - supply of paracetamol 500mg oral solid dosage form to patients with COVID-19 approaching the end of life requiring relief from pain or fever, by appropriate registered healthcare professionals in NHSScotland.

The purpose of the PGD is to help patients by providing them with more convenient access to treatment during the period of responding to COVID-19. It cannot be used until Appendix 1 is completed for each clinical area.

This PGD authorises appropriate registered healthcare professionals (see section titled:

Characteristics of staff authorised under the PGD) to supply paracetamol 500mg oral solid

dosage form to patients 16 years and older approaching the end of life with pain or fever,

and who meet the criteria for inclusion under the terms of the document.

Change history Person or group

responsible for changes

Date changes authorised Version number


54

Patient Group Direction for the supply of paracetamol 500mg oral solid dosage form

Authorisation

This PGD has been produced by the Area Drugs and Therapeutics Committee Collaborative and (insert group here) to assist NHS Boards to introduce this new service model in a uniform way across NHSScotland. NHS boards should ensure that the final PGD is

considered and approved in line with local clinical governance arrangements for PGDs. The qualified health professionals who may supply paracetamol 500mg oral solid dosage form under this PGD can only do so as named individuals. It is the responsibility of each

professional to practice within the bounds of their own competence and in accordance with their own Code of Professional Conduct, and to ensure familiarity with the marketing authorisation holder’s summary of product characteristics (SPC) for all medicines supplied in accordance with this PGD.

NHS board governance arrangements will indicate how records of staff authorised to operate this PGD will be maintained. Under PGD legislation there can be no delegation. Supply of the medicine has to be by the same practitioner who has assessed the patient

under the PGD. This PGD has been reviewed for NHS insert Board name by:

Doctor Click or tap here to enter text. Signature Click or tap here to enter text.

Pharmacist Click or tap here to enter text. Signature Click or tap here to enter text.

Nurse Click or tap here to enter text. Signature Click or tap here to enter text.

Approved on behalf of NHS insert Board name by:

Medical Director Click or tap here to enter

text. Signature Click or tap here to enter text.

Director of Pharmacy/Senior Pharmacist

Click or tap here to enter text. Signature Click or tap here to enter text.

Clinical

Governance Lead


Date Approved Click or tap to enter a date.

Effective from Click or tap to enter a date. Review Date

Click or tap to enter a date.

Clinical Situation

Definition of clinical situation/condition

Patients with COVID-19 approaching the end of life requiring symptomatic relief from pain or fever.


55

Clinical criteria for inclusion

Patients aged 16 years or older

Patient assessed as being in the end-of-life phase by an appropriately trained medical doctor.

Confirmed or suspected COVID-19

Informed consent by patient or patient advocate/carer

Patient or patient advocate/carer must be present at consultation (or involved remotely as appropriate)

Clinical criteria for

exclusion

Regularly takes another product which contains

paracetamol

Hypersensitivity to paracetamol and/or other constituents– review Summary of Product Characteristics of the products

under consideration

No valid consent

Lack of appropriate support/ability to administer oral paracetamol as instructed

Criteria for seeking

further clarification from doctor or independent prescriber

Any doubt as to inclusion/exclusion criteria being met.

Patients at increased risk of liver toxicity include:

Frail elderly

Adults with body weight <50kg

Chronic malnutrition/anorexia For the control of symptom at the end of life, the cautions listed in the BNF of manufacturer’s Summary of Product

Characteristics should not necessarily be a deterrent to the use of paracetamol.

Action if patient excluded from

treatment

Refer to medical doctor/non-medical independent prescriber and document in patient’s medical notes

Action if patient

declines`

Refer patient to medical doctor. The reason why the patient

declined treatment under the PGD will be documented in the patient’s medical notes

Description of Treatment

Name, form and strength of medicine

Paracetamol 500mg tablets, caplets, soluble tablets, effervescent tablets and capsules

Legal status GSL, P

Indicate any off-label use (if relevant)

Route/method of administration

Oral

Dose 500mg to 1000mg, 1 to 2 units of oral solid form dosage.


56

Consider reducing dose to 500mg in frail elderly, adults with body weight <50kg, and chronic malnutrition/ anorexia

Frequency of dose

Every 4 to 6 hours; maximum of 4 doses in 24 hour period

Duration of

treatment

While symptoms persist

Quantity to supply 1x32 of tablets, caplets or capsules, or 1x24 of soluble or effervescent tablets

Maximum or minimum treatment period

Not applicable

Advice to be given to patient before

treatment

Dosing information should be carefully explained and patient/carer understanding checked.

Do not take anything else containing paracetamol while taking this medicine.

Do not exceed the maximum of 4 doses in a 24 hour period

Written information

to be given to the patient or carer

The medicine manufacturer’s Patient Information Leaflet

should be given.

Follow-up advice to be given to patient or carer

If an adverse reaction is causing distress or there is insufficient relief from symptoms following treatment - seek medical advice from a General Practitioner or NHS 24 on 111

Identifying and managing possible

adverse reactions

Refer to BNF or Summary of Product Characteristics for a full list of side-effects.

If an adverse reaction does occur and continues to cause patient distress inform relevant medical practitioner as soon as possible. Report the reaction to the MHRA using the Yellow Card

System. https://yellowcard.mhra.gov.uk/ where appropriate.

Referral for medical advice

Appearance or suspicion of an adverse reaction or patient distress

Facilities and supplies required

Appropriate storage facilities for medicines Appropriately labelled supply Patient information leaflets

Special

considerations / additional information

Details of records required

Click or tap here to enter text.

References BNF No. 78 Available from: https://www.medicinescomplete.com/mc/bnf/current/

accessed on 02 April 2020 SPCs Available at: http://www.medicines.org.uk/emc accessed on: 02 April 2020

https://yellowcard.mhra.gov.uk/

https://www.medicinescomplete.com/mc/bnf/current/

http://www.medicines.org.uk/emc


57

Scottish Palliative Care Guidelines. Available from https://www.palliativecareguidelines.scot.nhs.uk/ accessed on 02 April 2020

Palliative Care Formulary. Available from https://www.medicinescomplete.com/#/browse/palliative accessed on 02 April 2020

Characteristics of staff authorised under the PGD

Professional

qualifications

Appropriate healthcare professionals for supplying include:

[Boards to adapt this list as appropriate]

Registered pharmacists.

Registered chiropodists and podiatrists.

Registered dental hygienist.

Registered dental therapist.

Registered dietitians.

Registered midwives.

Registered nurses.

Registered occupational therapists.

Registered optometrists.

Registered orthoptists.

Registered orthotists and prosthetists.

Registered paramedics.

Registered physiotherapists.

Registered radiographers.

Registered speech and language therapists. Under PGD legislation there can be no delegation. Supply of the medication has to be by the same practitioner who

has assessed the patient under this PGD. Specialist

competencies or qualifications

Able to assess the person’s (or advocate’s) capacity to

understand the nature and purpose of the medication in order to give or refuse consent. Must be familiar with the relevant paracetamol 500mg oral solid dosage form Summary of Product Characteristics (SPC).

Continuing

education and training

Aware of local treatment recommendations.

Attends approved training and training updates as appropriate.

Audit Trail

Record/Audit Trail

All records must be clear, legible and in an easily retrieval format.

Additional references

British National Formulary (BNF) current edition

MHRA guidance, Patient Group Direction: Who can use them.

Available on https://www.gov.uk/government/publications/patient-group-directions-pgds/patient-group-directions-who-can-use-them accessed on 02 April 2020

National Institute for Health and Care Excellence. Medicines

Practice Guideline: Patient Group Directions. Available on


https://www.medicinescomplete.com/#/browse/palliative

https://www.gov.uk/government/publications/patient-group-directions-pgds/patient-group-directions-who-can-use-them




58

https://www.nice.org.uk/guidance/mpg2/chapter/Recommendations#developing-patient-group-directions accessed on 02 April 2020

Appendix 1 Health professionals approved to provide care under the direction

The lead nurse/professional of each clinical area is responsible for maintaining records of all

clinical areas where this PGD is in use, and to whom it has been disseminated.

The manager who approves a healthcare professional to supply and/or administer medicines under

the patient group direction, is responsible for ensuring that he or she is competent, qualified and trained to do so and for maintaining an up-to-date record of such approved persons in conjunction with the Head of Profession.

The healthcare professional who is approved to supply and/or administer medicines under the

direction is responsible for ensuring that he or she has completed the PGD learnPro module,

understands and is qualified, trained and competent to undertake the duties required. The approved person is also responsible for ensuring that administration or supply is carried out within the terms of the direction, and according to his or her code of professional practice and conduct.

PATIENT GROUP DIRECTION : Supply of paracetamol 500mg oral solid dosage form from Community assessment centres or Emergency departments to patients with COVID-19 approaching the end of life requiring symptomatic relief from pain; by appropriate registered health professional in NHSScotland

Local clinical area(s) where these healthcare professionals will operate this PGD:

Name of Healthcare Professional

Signature Date Tick to confirm PGD learnPro module is completed

Name of Manager Signature Date

https://www.nice.org.uk/guidance/mpg2/chapter/Recommendations#developing-patient-group-directions



59





60


61

Appendix J: Patient Group Direction (PGD) template - supply of morphine sulfate 10mg/5ml oral solution to patients with COVID-19 approaching the end of life requiring relief from pain, breathlessness or cough by appropriate registered healthcare professionals in NHSScotland. Version – 1.0

The purpose of the PGD is to help patients by providing them with more convenient access to treatment during the period of responding to COVID-19. It cannot be used until Appendix

1 is completed for each clinical area.

This PGD authorises appropriate registered healthcare professionals (see section titled: Characteristics of staff authorised under the PGD) to supply morphine sulfate 10mg/5ml oral solution packs of 100ml to patients 16 years and older approaching the end of life with pain,

breathlessness or cough and who meet the criteria for inclusion under the terms of the document.

Change history

Person or group responsible for changes



62

Authorisation

This PGD has been produced by the Area Drugs and Therapeutics Committee

Collaborative Click or tap here to enter text. to assist NHS Boards to introduce this

new service model in a uniform way across NHSScotland. NHS boards should

ensure that the final PGD is considered and approved in line with local clinical

governance arrangements for PGDs.

The qualified health professionals who may supply morphine sulfate 10mg/5ml

oral solution under this PGD can only do so as named individuals. It is the

responsibility of each professional to practice within the bounds of their own

competence and in accordance with their own Code of Professional Conduct, and

to ensure familiarity with the marketing authorisation holder’s summary of

product characteristics (SPC) for all medicines supplied in accordance with this

PGD.

NHS board governance arrangements will indicate how records of staff authorised

to operate this PGD will be maintained. Under PGD legislation there can be no

delegation. Supply of the medicine has to be by the same practitioner who has

assessed the patient under the PGD.

This PGD has been reviewed for NHS insert Board name by:

Doctor Click or tap here to enter

text. Signature

Click or tap here to

enter text.

Pharmacist Click or tap here to enter

text. Signature


enter text.

Nurse Click or tap here to enter

text. Signature


enter text.


Medical Director Click or tap here to

enter text. Signature


enter text.

Director of

Pharmacy/Senior

Pharmacist




enter text.

Clinical

Governance Lead




enter text.

Date Approved Click or tap to enter

a date.

Effective from Click or tap to enter

a date.

Review

Date

Click or tap to enter a

date.

Clinical Situation


63

Definition of

clinical

situation/condition

Patients with COVID-19 approaching the end of life

requiring symptomatic relief from pain, breathlessness

or cough.


inclusion

Patients aged 16 years or older

Patient assessed as being in the end-of-life phase by

an appropriately trained medical doctor.


Informed consent by patient or patient

advocate/carer

Patient or patient advocate/carer must be present at

consultation (or involved remotely as appropriate)


exclusion

Known opioid hypersensitivity

No valid consent

Lack of appropriate support/ability to administer

morphine sulfate as instructed

The following are listed as contra-indications to

morphine in the BNF, however none of the

contraindications are absolute if treatment is titrated

carefully against a patient's symptoms.

Acute respiratory depression

Comatose patients

Head injury (opioid analgesics interfere with

pupillary responses vital for neurological

assessment)

Raised intracranial pressure (opioid analgesics

interfere with pupillary responses vital for

neurological assessment)

Risk of paralytic ileus

Acute abdominal conditions

Delayed gastric emptying

Heart failure secondary to chronic lung disease

Phaeochromocytoma

Criteria for

seeking further

clarification from

doctor or

independent

prescriber


For the control of symptoms at the end of life, the

cautions listed in the BNF or manufacturer’s Summary

of Product Characteristics should not necessarily be a

deterrent to the use of morphine sulfate.

Action if patient

excluded from

treatment

Refer to medical doctor/non-medical independent

prescriber and document in patient’s medical notes


64

Action if patient

declines`

Refer patient to medical doctor. The reason why the

patient declined treatment under the PGD will be

documented in the patient’s medical notes


Name, form and

strength of

medicine

Morphine sulfate oral solution 10mg/5ml

Legal status POM (Prescription Only Medicine), Controlled Drug

Schedule 5

Indicate any off-

label use (if

relevant)

Breathlessness and cough are off-label use

Route/method of

administration

Oral

Dose 2mg (1mL)

Frequency of

dose

Every 1 to 2 hours as required for symptoms. Maximum

of 3 doses in 4 hours and total maximum of 6 doses in 24

hour period

Duration of

treatment


Quantity to

supply

1 x 100mL

Maximum or

minimum

treatment period

Not applicable

Advice to be

given to patient

before

treatment

Dosing information should be carefully explained and

patient/carer understanding checked.

An oral syringe with appropriate graduations should be

supplied.

Morphine oral solution usually takes approximately 15

minutes to take effect.

Inform of possible side effects including nausea,

vomiting, and constipation and that supportive

treatments can manage these effects.

Morphine may cause confusion and drowsiness, if this

happens do not drive.


65

Written

information to

be given to the

patient or carer


should be given and the additional PIL associated with

the use of the medicine in this situation.

Follow-up

advice to be

given to patient

or carer

If an adverse reaction is causing distress or there is

insufficient relief from symptoms following treatment

instructions seek medical advice from a General

Practitioner or NHS 24 on 111

Identifying and

managing

possible adverse

reactions

Nausea, vomiting, constipation, drowsiness and confusion

are common side effects of morphine. Refer to BNF or

Summary of Product Characteristics for a full list of side-

effects. If an adverse reaction does occur and continues to cause

patient distress inform relevant medical practitioner as

soon as possible.

Report the reaction to the MHRA using the Yellow Card

System. https://yellowcard.mhra.gov.uk/ where

appropriate.

Referral for

medical advice

Appearance or suspicion of an adverse reaction or

patient distress.

Subtle hallucinations should be reported to your doctor

as these may indicate the dose of morphine requires

reviewed.

Facilities and

supplies

required

Appropriate storage facilities for medicines

Appropriately labelled supply of morphine oral solution

10mg/5ml.

Patient information leaflets

Special

considerations /

additional

information

Details of

records required


References BNF No. 78 Available from:


accessed on 02 April 2020

SPCs Available at: http://www.medicines.org.uk/emc

accessed on: 02 April 2020

Scottish Palliative Care Guidelines. Available from



Palliative Care Formulary. Available from









66


Professional

qualifications

Appropriate healthcare professionals for supplying a

POM CD5 include: [Boards to adapt this list as

appropriate]




Registered nurses.


Registered optometrists




Registered physiotherapists

Registered radiographers

Under PGD legislation there can be no delegation. Supply of the medication has to be by the same practitioner who has assessed the patient under this

PGD. Specialist

competencies or

qualifications

Able to assess the person’s capacity to understand the

nature and purpose of the medication in order to give

or refuse consent.

Must be familiar with the relevant morphine sulfate

10mg/5ml oral solution Summary of Product

Characteristics (SPC).

Continuing

education and

training

Aware of local treatment recommendations.

Attends approved training and training updates as

appropriate.

Audit Trail

Record/Audit

Trail

All records must be clear, legible and in an easily retrieval

format.

Additional

references


MHRA guidance, Patient Group Direction: Who can use

them. Available on

https://www.gov.uk/government/publications/patient-

group-directions-pgds/patient-group-directions-who-can-

use-them accessed on 02 April 2020

National Institute for Health and Care Excellence.

Medicines Practice Guideline: Patient Group Directions.

Available on

https://www.nice.org.uk/guidance/mpg2/chapter/Recomm






67

endations#developing-patient-group-directions accessed

on 02 April 2020

Specialist Pharmacy Services. Patient Group Direction.

Available from https://www.sps.nhs.uk/articles/who-can-

supply-or-administer-controlled-drugs-under-the-terms-

of-a-patient-group-direction-and-under-what-

circumstances/ accessed on 02 April 2020

Appendix 1

Health professionals approved to provide care under the direction

The lead nurse/professional of each clinical area is responsible for maintaining records of

all clinical areas where this PGD is in use, and to whom it has been disseminated.

The manager who approves a healthcare professional to supply and/or administer

medicines under the patient group direction, is responsible for ensuring that he or she is

competent, qualified and trained to do so and for maintaining an up-to-date record of

such approved persons in conjunction with the Head of Profession.

The healthcare professional who is approved to supply and/or administer medicines

under the direction is responsible for ensuring that he or she has completed the PGD

learnPro module, understands and is qualified, trained and competent to undertake the

duties required. The approved person is also responsible for ensuring that administration

or supply is carried out within the terms of the direction, and according to his or her code

of professional practice and conduct.

PATIENT GROUP DIRECTION : Supply of morphine sulfate oral solution 10mg/5ml from

Community assessment centres or Emergency departments to patients with COVID-19

approaching the end of life requiring symptomatic relief from pain, breathlessness or

cough; by appropriate registered health professional in NHSScotland






https://www.sps.nhs.uk/articles/who-can-supply-or-administer-controlled-drugs-under-the-terms-of-a-patient-group-direction-and-under-what-circumstances/





68





69


70

Appendix K: Patient Group Direction (PGD) template - supply of lorazepam 1mg tablets, to patients with COVID-19 approaching the end of life requiring relief from anxiety and distress, by appropriate registered healthcare professionals in NHS Scotland.

Version – 0.1

The purpose of the PGD is to help patients by providing them with more convenient access to treatment during the period of responding to COVID-19. It cannot be used until Appendix

1 is completed for each clinical area.

This PGD authorises appropriate registered healthcare professionals (see section titled: Characteristics of staff authorised under the PGD) to supply lorazepam 1mg tablets packs of 10 tablets to patients 16 years and older approaching the end of life with anxiety or

distress and who meet the criteria for inclusion under the terms of the document.

Change history

Person or group responsible for changes



71

Patient Group Direction for the supply of lorazepam 1mg tablets (manufactured by Genus, PVL or TEVA); pack size 10 tablets, legally classified as a Prescription Only Medicine Controlled Drug Schedule 4 Part 1

Authorisation

This PGD has been produced by the Area Drugs and Therapeutics Committee Collaborative Click or tap here to enter text. to assist NHS Boards to introduce this new service model in a

uniform way across NHSScotland. NHS boards should ensure that the final PGD is

considered and approved in line with local clinical governance arrangements for PGDs. The qualified health professionals who may supply lorazepam 1mg tablets under this PGD can only do so as named individuals. It is the responsibility of each professional to practice

within the bounds of their own competence and in accordance with their own Code of Professional Conduct, and to ensure familiarity with the marketing authorisation holder’s summary of product characteristics (SPC) for all medicines supplied in accordance with this PGD.

NHS board governance arrangements will indicate how records of staff authorised to operate this PGD will be maintained. Under PGD legislation there can be no delegation. Supply of the medicine has to be by the same practitioner who has assessed the patient

under the PGD. This PGD has been reviewed for NHS insert Board name by:

Doctor Click or tap here to enter text. Signature Click or tap here to enter text.

Pharmacist Click or tap here to enter text. Signature Click or tap here to enter text.

Nurse Click or tap here to enter text. Signature Click or tap here to enter text.


Medical Director Click or tap here to enter


Director of Pharmacy/Senior Pharmacist

Click or tap here to enter


Clinical

Governance Lead


Date Approved Click or tap to enter a date.

Effective from Click or tap to enter a date. Review Date

Click or tap to enter a date.


72

Clinical Situation

Definition of clinical situation/condition

Patients with COVID-19 approaching the end of life requiring symptomatic relief from anxiety or distress.


inclusion Patients aged 16 years or older

Patient assessed as being in the end-of-life phase by an appropriately trained medical doctor.


Informed consent by patient or patient advocate/carer

Patient or patient advocate/carer must be present at consultation (or involved remotely as appropriate)

Clinical criteria for exclusion

Known benzodiazepine hypersensitivity

No valid consent

Lack of appropriate support/ability to administer lorazepam as instructed

The following are listed as contra-indications to

benzodiazepines and lorazepam in the BNF, however none of the contraindications are absolute if treatment is titrated carefully against a patient's symptoms.

Acute pulmonary insufficiency

Marked neuromuscular respiratory weakness

chronic psychosis

Sleep apnoea syndrome

Unstable myasthenia gravis

CNS depression

Compromised airway

Respiratory depression

Criteria for seeking further clarification from doctor or independent

prescriber


Action if patient excluded from treatment

Refer to medical doctor/non-medical independent prescriber and document in patient’s medical notes

Action if patient declines`

Refer patient to medical doctor. The reason why the patient declined treatment under the PGD will be documented in the patient’s medical notes


Name, form and strength of medicine

Lorazepam 1mg tablets for sublingual use (manufactured by Genus, PVL or TEVA)


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Legal status Prescription Only Medicine, Controlled Drug Schedule 4 part 1

Indicate any off-label use (if relevant)

Sublingual route is off-label use

Route/method of administration

Sublingual, put half a tablet under the tongue and leave to dissolve.

If mouth dry, moisten first with sips of water, otherwise tablet will not dissolve.

Dose Half of a 1mg tablet (500 micrograms)

Frequency of dose

Every 4 hours as required for symptoms; maximum of 4 doses in 24 hour period

Duration of treatment


Quantity to supply 10

Maximum or minimum treatment period

Not applicable

Advice to be given to patient before

treatment

Dosing information should be carefully explained and patient/carer understanding checked.

Inform of possible side effects including decreased alertness, confusion, drowsiness, paradoxical increase in anxiety, agitation or aggression, and how to manage these effects.

Lorazepam may cause confusion and drowsiness, if this happens do not drive.

Written information

to be given to the patient or carer


should be given and the additional PIL associated with the use of the medicine in this situation.

Follow-up advice to be given to patient or carer

If an adverse reaction is causing distress or there is insufficient relief from symptoms following treatment instructions seek medical advice from a General Practitioner or NHS 24 on 111.

Identifying and

managing possible adverse reactions

Confusion, drowsiness, dizziness and decreased alertness

are common side effects of lorazepam. Refer to BNF or Summary of Product Characteristics for a full list of side-effects. If an adverse reaction does occur and continues to cause

patient distress inform relevant medical practitioner as soon as possible. Report the reaction to the MHRA using the Yellow Card System. https://yellowcard.mhra.gov.uk/ where appropriate.

Referral for medical advice

Appearance or suspicion of an adverse reaction or patient distress

Facilities and supplies required

Appropriate storage facilities for medicines Appropriately labelled supply of lorazepam tablets. Patient information leaflets



74

Special considerations / additional

information

Details of records required


References BNF No. 78 Available from: https://www.medicinescomplete.com/mc/bnf/current/ accessed on 03 April 2020 SPCs Available at: http://www.medicines.org.uk/emc

accessed on: 03 April 2020 Scottish Palliative Care Guidelines. Available from https://www.palliativecareguidelines.scot.nhs.uk/ accessed on 03 April 2020

Palliative Care Formulary. Available from https://www.medicinescomplete.com/#/browse/palliative accessed on 03 April 2020


Professional

qualifications

Appropriate healthcare professionals for supplying lorazepam

(a POM CD4 Part 1 medicine) include: [Boards to adapt this list as appropriate]




Registered nurses.


Registered optometrists




Registered physiotherapists

Registered radiographers Under PGD legislation there can be no delegation.

Supply of the medication has to be by the same practitioner who has assessed the patient under this PGD.

Specialist competencies or qualifications

Able to assess the person’s capacity to understand the nature and purpose of the medication in order to give or refuse consent.

Must be familiar with the relevant lorazepam 1mg tablets Summary of Product Characteristics (SPC).

Continuing education and training

Aware of local treatment recommendations. Attends approved training and training updates as appropriate.






75

Audit Trail

Record/Audit

Trail

All records must be clear, legible and in an easily retrieval format.

Additional references


MHRA guidance, Patient Group Direction: Who can use them. Available on https://www.gov.uk/government/publications/patient-group-directions-pgds/patient-group-directions-who-can-use-

them accessed on 03 April 2020

National Institute for Health and Care Excellence. Medicines Practice Guideline: Patient Group Directions. Available on https://www.nice.org.uk/guidance/mpg2/chapter/Recommendatio

ns#developing-patient-group-directions accessed on 03 April 2020

Specialist Pharmacy Service Coronavirus (COVID-19) Available at

https://www.sps.nhs.uk/articles/who-can-supply-or-administer-controlled-drugs-under-the-terms-of-a-patient-group-direction-and-under-what-circumstances/ accessed on 03 April 2020

Appendix 1 Health professionals approved to provide care under the direction

The lead nurse/professional of each clinical area is responsible for maintaining records of all

clinical areas where this PGD is in use, and to whom it has been disseminated.

The manager who approves a healthcare professional to supply and/or administer medicines under

the patient group direction, is responsible for ensuring that he or she is competent, qualified and trained to do so and for maintaining an up-to-date record of such approved persons in conjunction with the Head of Profession.

The healthcare professional who is approved to supply and/or administer medicines under the

direction is responsible for ensuring that he or she has completed the PGD learnPro module,

understands and is qualified, trained and competent to undertake the duties required. The approved person is also responsible for ensuring that administration or supply is carried out within the terms of the direction, and according to his or her code of professional practice and conduct.

PATIENT GROUP DIRECTION : Supply of lorazepam 1mg tablets from Community

assessment centres or Emergency departments to patients with COVID-19 approaching the end of life requiring symptomatic relief from anxiety or distress; by appropriate registered health professional in NHSScotland











76








77


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Appendix L: Patient Leaflet - Supply of medicines for control of symptoms

What are ‘Just in case’ medicines?

Just in case medicines are a range of medicines that can be given to take home to

help relieve pain or other symptoms.

You will have been told if you should continue to take your usual medicines. Your

usual oral medicines (e.g. painkillers) should be tried first to see if they help to

relieve your symptoms.

What are the ‘Just in case’ medicines for?

You may not need any of these medicines right now, however, they have been

prescribed for you because your healthcare team think that they may be needed

at some point in the coming days to help with:

pain relief

cough/ breathlessness or breathing (especially if you're unable to clear

your own throat)

anxiety or restlessness

The healthcare professional who gives you the ‘just in case’ medicines will assess

you and will agree a plan with you and your carer about what to do if your usual

medicines need to be changed or if another dose of the ‘Just in case’ medicine is

needed.

Who can/should give you ‘Just in case’ medicines?

These ‘just in case’ medicines can be taken by you or given to you by your carer.

The medicines that are supplied are for oral use (to be swallowed). The medicines

will either have a dispensing label with instructions (similar to what you would

receive from a community pharmacy) or instructions will be available from the

patient information leaflet provided with the medicine.

Information below provides further details on how to take these medicines in

addition to the Patient Information Leaflets (PIL) that are provided with the

medicines.

Your doctor / clinician will supply you with enough medicine at this time to treat

your symptom. If a further supply of medicines is required you or your carer

should let you GP know. If your condition changes, you or your carer should let

your GP practice or community nurse (in hours)/the NHS 24 111 service (out of

hours) know so that they can reassess you and make sure your regular medicines,

the ‘Just in case’ medicines, and their doses, are still right for you.

If you are admitted to hospital or another care setting, the medicines can go with

you as they have been prescribed for you. If you're unable or do not wish to do

this, please let the staff know that you have them in the house.


79

If ‘Just in case’ medicines or any other medicines are no longer needed, they

should be returned to your community pharmacy or dispensing doctor in a plastic

bag. Further information on returning unused medicines can be found at -

https://www.nhsinform.scot/illnesses-and-conditions/infections-and-poisoning/coronavirus-

covid-19/coronavirus-covid-19-general-advice#common-questions

Morphine and Lorazepam for Treatment of Shortness of Breath, Cough and

Anxiety.

All medicines are supplied with a manufacturer’s ‘Patient Information Leaflet’. This

can provide a great deal of information about the medicine, its normal uses and

side effects. However, most medicines have more than one effect on the body and

for many years, it has been known that certain medicines are safe and effective

for the treatment of symptoms other than those specified by the medicine’s

manufacturer and there is now plenty of evidence to confirm such use.

We are providing you with this extra information to inform you of the reason(s)

why you are taking this medicine and to highlight any other information. This

should be read in conjunction with the attached manufacturer’s patient

information leaflet.

Lorazepam 1mg tablets

Lorazepam is sometimes used for anxiety or distress, which may feel worse if you

are short of breath. Instead of swallowing the tablet you allow it to dissolve under

your tongue.

Frequently asked questions

Q. What form(s) of this medicine are there and how is it usually taken?

A. This medicine is normally available as a tablet. The dose prescribed is normally

between half a 1mg tablet (0.5mg or 500 micrograms) to one 1mg tablet. It has

been prescribed to be taken when needed for shortness of breath or anxiety. You

usually place this dose under your tongue. Under the tongue (sublingual)

lorazepam tablets start to work within 10 to 20 minutes of taking a dose for

breathlessness and usually last for about eight hours. You can place a dose under

the tongue every four to six hours, however you may not need as much as this.

The maximum number of doses that you can take is 4 doses in 24 hours.

Because the medicine gets into your body easily from the soft tissue in your

mouth, you should place the tablet under your tongue and keep it there until it

has fully dissolved. Before taking this medicine, make sure your mouth is moist by

taking some water. This will help the tablet dissolve better under your tongue. The

tablets can be swallowed instead of placing under the tongue, but will take a little

longer to get into your body to have the same effect.

Note: Always follow the dose indicated on the label or advised by a healthcare

professional.




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Q. What are the most common side effects I might experience?

A. Lorazepam might make you sleepy (drowsy) shortly after you take it. Because

of this, we advise you to rest for a while in a comfortable chair or bed

immediately after you take the dose. You should not drive immediately after

taking lorazepam or if it makes you sleepy. Drowsiness is more likely to occur if

you are taking other medicines that cause sleepiness. Please inform your doctor

or pharmacist of any other medicines you are taking.

Occasionally, you may also experience light headedness (dizziness) and a dry

mouth. If you do experience light headedness which lasts for a long time, let your

doctor or pharmacist know.

Drinking alcohol may also make these side effects worse.

Q. What do I do if I forget to take a dose?

A. Take a dose as soon as you remember. Do not take a double dose to make up

for the missed one. If you are sick and bring up the medicine within 30 minutes of

taking it, repeat the dose as soon as you feel better.

Safe storage

Your medication needs to be kept in a safe place out of the reach of children. It

needs to be stored in the original container. Return unused medication to a

pharmacy in a plastic bag. For further information on returning unused medicines

please see the link to NHS Inform above.

Morphine Sulfate Oral Solution 10mg/5ml

Morphine has been used as a treatment for breathlessness for many years and is

proven to be effective and safe. It can also be useful to treat a very persistent

cough.

If you have been prescribed the morphine to use for pain, follow the directions

you have been given and read the manufacturer’s Patient Information Leaflet

supplied with it.

Frequently asked questions

Q. What form(s) of this medicine are there and how is it usually taken?

A. Morphine works quickly to relieve coughing and the feeling of being breathless.

You will usually be started on a small dose of morphine, around 2mg which is 1ml

of the oral solution. This will start to work within 10 to 20 minutes after taking a

dose for breathlessness. Usually the effect of the morphine will last between 2 to

3 hours. You may need to take the morphine every 1 to 2 hours initially to help


81

relieve symptoms. If you need to take more than 3 doses of morphine in 4 hours

or 6 doses of morphine in 24-hours, please contact your GP, nurse or pharmacist

for advice as your dose may need to be increased. Measure the morphine solution

(liquid) out from the bottle with an oral syringe (a syringe which is specially

designed to use with medicines you take by mouth) and squeeze it gently into

your mouth and swallow.

Q. What are the most common side effects I might experience?

A. As with all medicine there may be side effects which can include:

Constipation – it may be useful to take a laxative while taking morphine

Nausea and vomiting

• Drowsiness (sleepiness), if you do feel drowsy it is important that you do

not drive

Skin itching, and

Dry mouth.

Nausea, itching and drowsiness usually go away over time and with continued use

of morphine. If any of these symptoms are making you feel unwell contact your

GP. If you are taking other medicines which make you sleepy or have drunk

alcohol, this may make you even sleepier.

Dry mouth

Try to keep your mouth and lips clean and moist. Brush your teeth regularly

morning and night with fluoride toothpaste, preferably not immediately after

taking a dose of morphine. Frequent cool drinks, sips of water and ice cubes may

help. If your mouth becomes sore, please see your healthcare professional for

advice and help.

Q. Is morphine dangerous, will I become addicted?

A. Some people may feel concerned at the thought of using morphine for several

reasons:

• Some people may recognize this as a medicine used for pain including

when someone has cancer or is dying. This is absolutely not why morphine

is used for breathlessness.

• Some people may think that using morphine will make you addicted. The

small amount of morphine used to treat breathlessness does not cause

addiction. The morphine can be safely reduced and stopped if it does not

benefit you, or if you no longer need it.

• You might notice that the packet information leaflet includes a warning

that states that it is dangerous to take morphine when you have a breathing

condition. This is only a possible problem if you need to take very large

doses of morphine to treat pain. It is safe and helpful to you in the low

doses prescribed for treating breathlessness.


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It is important to let your doctor know if you feel the morphine is not helping, as

it may be that you need a larger dose regularly, or other medicines may help. If

you are taking more frequent doses of morphine you may feel unwell in one or

more of these ways:

more sleepy than usual

feeling sick more of the time

restlessness or jumpiness, and

bad dreams and/or confusion.

Should this happen, please tell your prescriber as they may want to review your

medicine for breathlessness.

Safe storage

Your medication needs to be kept in a safe place out of the reach of children. It

needs to be stored in the original container. Please return unused medication to a

pharmacy in a plastic bag. For further information on returning unused medicines

please see the link to NHS Inform above.


83

Appendix M: Coronavirus in care homes – visual


84

Appendix N: Administration of palliative care medicine for care home residents at end of life (courtesy of SPCPS based on a Model of Care developed by NHSGG&C)

Symptom of COVID-19

Medicines administered by a carer Medicines administered by nursing staff/trained staff (subcutaneous administration)


85

Homely remedy – stock in care

home

Prescribed on a GP10 -

access via community

pharmacy

Medication stocked

in care homes – via

protocol

Just in case box

medicines/palliative

care amps – via

GP10

Pain Paracetamol tablets/soluble tablets

(500mg)/liquid

(250mg/5ml)/suppositories(500mg/1g)

Morphine 10mg/5ml liquid

Buprenorphine patch

Fentanyl patch

Diclofenac suppositories

Morphine/oxycodone/

alfentanil injection

Nausea &

vomiting

Prochlorperazine 3mg tabs

Hyoscine hydrobromide

300microgram tablets

Hyoscine hydrobromide 1.5mg patch

Can be given orally or

sublingually

Levomepromazine 6mg

tablets

Ondansetron 4mg

orodispersible tablets

Olanzepine orodispersible

tablets

Levomepromazine

injection

Breathlessness Non-pharmacological measures Morphine 10mg/5ml liquid

Buccal midazolam

Midazolam injection

Morphine injection

Cough Codeine linctus 15mg/5ml liquid Morphine 10mg/5ml liquid Morphine injection

Respiratory

secretions

Hyoscine hydrobromide

300microgram tabs

Hyoscine hydrobromide 1.5mg patch

Ipratropium inhaler Hyoscine

butylbromide

Hyoscine

hydrobromide/

Hyoscine

butylbromide/

Glycopyrronium

Anxiety and

distress

- Lorazepam 1mg tablets -

sublingual

Buccal midazolam

Diazepam rectal tubes

Levomepromazine

injection

Midazolam injection


86

Delirium and

agitation

- Levomepromazine tablets -

sublingual

Olanzepine oro-dispersible

tablets (sublingual)

Buccal midazolam

Levomepromazine

injection

Haloperidol injection

Haloperidol injection

Midazolam amps

Levomepromazine

amps

Seizures - Buccal midazolam

Diazepam rectal tubes

Carbamazepine suppositories

Midazolam


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Appendix O – Summary of issues to be considered to support care home residents accessing palliative care medicines during the COVID-19 pandemic (courtesy of SPCPS)

Priority area Action

Shortage of GP prescribers Support the prescribing of dose ranges (see

Appendix A)

Local arrangement

Identify any other prescribers non-medical

prescribers

Local arrangements

Access to JICB medicines Distribute JICB kardexes to all care homes – local

arrangement

Prescribe anticipatory JICB medicines to all

residents in advance, when COVID-19 is confirmed.

Do not dispense until needed to reduce wastage.

Ensure timely access to palliative care medicines

via palliative care pharmacies or local

arrangements for OOH

Care homes Update the homely remedy policy to include GSL/P

medicines that a carer could give to a care home

resident to help alleviate symptoms

Update the homely remedy policy.

See sample protocols from NHS GG&C.

Care homes may stock prescription only medicines

for symptoms of COVID-19 (for example hyoscine

butylbromide for secretions) if the requirements of

the pandemic exemption (Medicines Regulation

247) are met

New policy required to support this which includes

the development of board approved disease

protocols. See sample protocols from NHS GG&C.

Care homes can stock two of the medicines in the

JICB (levomepromazine and hyoscine

butylbromide) in the care home to improve access

to these medicines, for end of life care

New policy required to support this which includes

the development of board approved disease

protocols. See sample protocols from NHS GG&C.


http://www.legislation.gov.uk/uksi/2012/1916/regulation/247/made

http://www.legislation.gov.uk/uksi/2012/1916/regulation/247/made




88

Community Pharmacy Care Home residents can access standard palliative

care medicines and alternative palliative care

medicines that a carer could administer on a GP10

via the community pharmacy.

See the ‘alternatives to regular medication normally

given via a syringe pump when this is not available’

guideline at

www.palliativecareguidelines.scot.nhs.uk.

Local arrangement

Just in Case Boxes Need to be prescribed on a GP10 and dispensed by

community pharmacy

All JICB medicines are given subcutaneously so

need to be administered by a nurse/trained staff.

Shortage of essential

palliative care medicines

Care home staff being able to access information

about medicine supply issues

SPCPA/ community pharmacists/ local

arrangements to provide advice and recommend

alternatives

http://www.palliativecareguidelines.scot.nhs.uk/


89

Appendix P – Members of Working Group for the Palliative Care Toolkit

Name Surname Role Organisation

Alison Strath Principal

Pharmaceutical

Officer

Scottish Government

Anne Wilson Palliative Care

Pharmacist

NHS Forth Valley

Joanne Barton Technical Manager,

Operations and

Medicines

Management

NHS Greater Glasgow and Clyde

Morgan Reilly Senior Policy

Manager

Scottish Government

Noreen Downes Principal

Pharmacist

Scottish Medicine Consortium,

Healthcare Improvement Scotland

Scott Hill National Clinical

Lead (Pharmacy)

Area Drug and Therapeutics

Committee Collaborative and

Scottish Medicines Consortium,

Healthcare Improvement Scotland

Members of the Scottish Palliative Care Pharmacy Association (SPCPA) and

colleagues from across health and social care who provided advice and feedback

on the development of the toolkit are thanked for their contribution.

Queries or comments related to the toolkit can be sent to: [email protected]

mailto:[email protected]


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