A model of intended and ideal prescribing and medication use in symptom control in palliative care: an international scoping review
Authors: Francis S A , Yardley S , Franklin B , Ogden M , Kajamaa A , Mattick K 
Published: November 2023

Abstract

Introduction
UK health policy documents are committed to improving personalised palliative care for people of all ages, prioritising access to coordinated care and health inequity. The UK Health and Care Act 2022 has stated it is a statutory requirement for Integrated Care Boards to commission palliative and end of life care services.
Palliative care focuses on improving the quality of life of patients and families who are facing problems associated with life-limiting illness, and often involves medication for symptom control.
Medication has been reported in 19% of NHS serious incident reports involving palliative patients, mostly occurring in patient homes, with half when specialists did not provide care.1

Aim
To document a model of existing evidence illustrating intended processes when palliative medications are prescribed for symptom control and used by adults at home, in hospital and hospice settings.

Methods
We performed a scoping review using JBI methodology.2 Population (P): (i) adults in the last phase of life, (ii) informal carers supporting an adult as described above, (iii) healthcare professionals providing palliative care for symptom control. Concept (C): multistep processes for medication use for symptom control in palliative care. Context (C): care settings where palliative care may be anticipated, planned or happen.
A systematic search were undertaken in Medline, CINAHL, Embase, plus Google scholar and Google images. There were no date limits; searches were confined to English language. Published and unpublished literature meeting the PCC framework were included. Screening and extraction of data were performed by two independent reviewers (SAF and SY). Studies were categorised inductively and results collated descriptively.
Ethical approval was obtained from the NHS HRA and HCRW (ref: 21/LO/0459).

Results
19,753 titles and abstracts were screened; 929 underwent full text review; 308 peer-reviewed articles and grey literature documents were retained to build the intended model. The majority of these papers (212; 69%) provided simple process steps involving expertise/judgement, supply chain/access, administration, prescribing/deprescribing, rationalisation, repurposing. The remaining 96 papers warranted richer thematic analysis. Most studies took place in the UK, Australia or USA in home/community settings. Analysis illuminated detail about ‘hidden work’ (participants’ actions in medication management), ‘hot spots’ (problematic areas e.g. out-of-hours care and the reliance on carers) and ‘cold spots’ (areas with less attention such as whose responsibility for keeping carers informed of changes and what is adequate support for safe medicines use at home).

Discussion/Conclusion
There is a growing interest in how best to work together across boundaries to enable getting the right medication to the right person at the right time and place. This scoping review documents the existing evidence of intended processes and a model of ideal prescribing and medication use in symptom control in palliative care. This study is limited to adult palliative care services only. A strength of the study is the use of JBI methodology. Using ethnographic methods and the conceptual tools of Activity Theory, we will refine this intended model with a study of what happens in practice3 to build a theoretically-informed, empirically-evidenced model of medication management across palliative care contexts.

References
1. Yardley I, Yardley S, Williams H, Carson-Stevens A, Donaldson L. Patient safety in palliative care: A mixed-methods study of reports to a national database of serious incidents. Pall Med 2018;32:1353-1362.
2. The Joanna Briggs Institute. Joanna Briggs Institute Reviewers’ Manual: 2015 edition / supplement: Methodology for JBI Scoping Reviews. Adelaide, Australia: The Joanna Briggs Institute 2015. http://joannabriggs.org/assets/docs/sumari/Reviewers-Manual_Methodology-for-JBI-Scoping-Reviews_2015_v2.pdf
3. Yardley S, Francis SA, Dean Franklin B, Ogden M, Kajamaa A, Mattick K. Getting palliative medications right across the contexts of homes, hospitals and hospices: protocol to synthesise scoping review and ethnographic methods in an activity theory analysis. BMJ Open 2022 12:e061754.