Pre-emptive prescribing for palliative care patients in primary care

Background One of the challenges of palliative care at home is ensuring good symptom control, including access to medication out of hours. One potential solution is ‘pre-emptive prescribing’ (PEP) of medicines in advance of need. Aims To evaluate pre-emptive prescribing with respect to: (1) Prevalence in GP end of life care (2) Factors influencing its use (3) Association with likelihood of home death (4) Impact on utilisation of healthcare in the last month of life. Methods Retrospective examination of the records of all deaths occurring during 2009 in twelve diverse Cambridgeshire GP practices. Results PEP was used in 16% of predictable deaths: levels of usage varied widely between practices. Receiving a PEP was associated with having a recorded preferred place of death (OR 2.14, 95% CI 1.46 to 3.12) and being on the practice palliative care register (OR 2.23, 95% CI 1.24 to 4.00). Those living at home were less likely than those in care homes to receive a PEP (OR 0.53, 95% CI 0.31 to 0.89). The use of PEP was associated with increased chance of death at home in all groups, an effect modulated by the patient9s usual place of residence (own home or care home) and history of previous hospital admissions (OR 6.02, 95% CI 1.70 to 21.2 for subgroup living in own home with previous hospital admissions). PEP use was also associated with decreased risk of hospitalisation in last month of life, and increased GP contact in both care home and community residents: it did not appear to affect hospice admissions of GP out-of-hours service contacts. Conclusions This is the first study to evaluate the use of PEP in primary care. There was a strong association with home death and decreased hospital admissions: however, a causal association is not demonstrated, and the active component of the intervention remains unclear.