Pre-emptive prescribing for syringe pumps – safe practice?

A letter in the recent BMJ Supportive and Palliative care journal(1) has raised questions on the safety of prescribing for 24-hour syringe pumps ahead of need. It reflects that the Gosport War Memorial inquiry has increased public and clinical awareness of the use of syringe pumps for the delivery of opioids. Whilst we know in safe hands they facilitate the best symptom control for patients who are no longer able to swallow their oral medicines, the authors question whether prescribing anticipatory syringe pump prescriptions can still be justified.

The authors make it plain that practice at Gosport bears no comparison to hospice practice, essentially because the patients who died were in the Memorial Hospital for rehabilitation and were not diagnosed with a terminal illness. They do, however, raise a point which we could extrapolate to the care of dying patients in settings where the healthcare professional given the responsibility for setting up a syringe driver may not have the assessment skills required. This could apply to the hospital setting where there is no regular palliative care input or at home where district nurses might be the healthcare professionals who fill the first syringe. The article clearly differentiates between the prescribing of ‘just-in-case’ medicines intended for p.r.n. use and the initiation of a continuous infusion, which marks a more significant change in a patient’s clinical status.

As hospice clinicians, we regularly have the sensitive and compassionate discussions with patients and families about the significance of starting the pump, the fact that it is unlikely to be withdrawn once started and, most importantly, that the aim of the contents is purely to deliver a continuous dose and not hasten the dying process. Stigma still exists when syringe drivers are mentioned and people understandably associate them with imminent death without perhaps appreciating that they are the most comfortable way to ensure a peaceful death and not the cause of it. In a specialist unit and community teams, staff work closely together and discuss use of p.r.n and syringe pumps, although we do not all routinely audit this practice.

The article reports that a snapshot survey of GPs showed that 2 of the 13 GPs who responded said they felt comfortable with providing anticipatory syringe driver prescriptions and trusted their community nursing colleagues to give the drugs appropriately. The other 11 felt that syringe pumps should only be prescribed in response to symptoms developing after a doctor had seen a patient and been unable to uncover any reversible symptoms. The authors state that there is no clear guidance from NICE on the use of ‘just-in-case’ medicines so they end with the recommendation that syringe pumps should only be started after a full clinical assessment to ensure correct diagnosis of dying.

Other documents, such as the report on the Liverpool Care Pathway, ‘One chance to get it right,(2) are also cautious about setting up syringe pumps but they rightly focus more on the need for good communication prior to the change in drug delivery.

This caution feels rational and would certainly go some way to preventing the poor practice revealed in the report on incidents in Gosport, but might it result in slower responses to symptoms and less effective end of life care?

Despite no specific guidance from NICE, we have many advisory documents and references. ‘Transforming end of life care in acute hospitals’(3) describes over 138 pages how to better communicate and co-ordinate this care. The National Framework 2015–2020 – Ambitions for Palliative and End of Life Care(4) states we should all have access to 24-hour care and that care must be co-ordinated. However, these need to be weighed against the likelihood of dying patients having access to a prompt and timely visit from a clinician with the expertise and willingness to do this. Current practice is built on too many sad instances where patients have been left in pain and distress because no one could come to their bedside.

The ‘BMJ Supportive and Palliative Care’ article opens a debate that feels timely but it is essential that the principles are applied in a balanced way to ensure we do not go backwards in our management of end of life care. It may be safer in non-specialist settings only to prescribe anticipatory injections for p.r.n use and write prescriptions for syringe pumps only once need has been established and all concerned agree that the person is actively dying. However, we need to be confident that a prescriber will be available to write that prescription as soon as is it necessary to avoid any deterioration in symptoms. It will be interesting to see how this impacts on practice.