Simultaneously reassuring and unsettling: a longitudinal qualitative study of community anticipatory medication prescribing for older patients

Abstract

Abstract Background The prescription of injectable anticipatory medications is widely accepted by clinicians to be key in facilitating effective last-days-of-life symptom control. Community end-of-life care and admission avoidance is particularly strongly advocated for older patients. However, patient and informal caregiver views and experiences of anticipatory medication have been little studied to date. Objective To understand older patients’, informal caregivers’ and clinicians’ views and experiences of the prescribing and use of anticipatory medications. Design Qualitative study. Setting Patients’ homes and residential care homes. Participants Purposive sample of six older patients, nine informal caregivers and six clinicians. Methods Multi-perspective, longitudinal interview study based on 11 patient cases. Semi-structured interviews (n = 28) were analysed thematically. Results Three themes were identified: (i) living in the present whilst making plans: anticipatory medications were used by clinicians as a practical tool in planning for uncertainty, while patients and informal caregivers tried to concentrate on living in the present; (ii) anticipation of dying: it was rare for patients and informal caregivers to discuss explicitly the process and experience of dying with clinicians; and (iii) accessing timely care: the use of anticipatory medications generally helped symptom control. However, informal caregivers reported difficulties in persuading nurses to administer them to patients. Conclusions Anticipatory medications are simultaneously reassuring and a source of unease to older patients and their informal caregivers. Prescriptions need careful discussion and tailoring to their preferences and experience. Nurses’ decisions to administer medication should consider informal caregivers’ insights into patient distress, especially when patients can no longer communicate their needs.