Prescribing in the Last Year of Life, and associations with demographic factors, cancer type and unscheduled care use, in people who die from cancer.

Problem

People dying from cancer often experience disease-and-treatment-related symptoms. Provision of medication to help with symptom control is a vital part of community palliative care, and an essential element in achieving a good quality of life in people living with advanced cancer. Little is known about the associations between demographic and clinical factors on provision of prescription medication to people dying from cancer, or the influence that prescribing practices have on unscheduled care use by cancer decedents. In the UK, this unscheduled care is delivered by GP-Out-Of-Hours (GPOOH) and Accident & Emergency (A&E).

Approach

This retrospective cohort study, of all 2,443 people who died from cancer in Tayside, Scotland from 03/2013-06/2015, aimed to understand the patterns and outcomes of unscheduled care attendance in the last 12 months of life, at GPOOH and A&E, by people who die from cancer, and to examine the associations with prescribing factors. Clinical, demographic, cancer registry and prescribing datasets were linked to routinely collected clinical data using the Community Health Index (CHI) number. Anonymised linked data were analysed in SafeHaven. Analysis was descriptive, using Poisson regression.

Findings

Three in four cancer decedents were prescribed strong opioids. Two-thirds of those prescribed opioids were also prescribed laxatives and/or anti-emetics, with only four in ten being prescribed ‘Just in case’ medication categories and one in ten receiving breakthrough analgesia. The number of prescriptions for analgesia and palliative care drugs increased in the last 12 weeks of life. Cancer decedents who were female, younger, or had lung cancer, were more likely to be prescribed strong opioids. Having a late diagnosis of cancer was associated with increased odds of being prescribed weak opioids and decreased odds of being prescribed strong opioids. Cancer decedents who attended unscheduled care received more prescriptions per person in all drug categories, compared to those who did not. Cancer decedents who attended A&E, versus those who did not, had a higher number of prescriptions for most analgesia; those who attended GPOOH, versus those who did not, had a higher number of prescriptions for all drugs. Frequent or very frequent attenders received more than double the number of prescriptions per person that non-attenders.

Consequences

This research identified multiple prescribing factors associated with increased unscheduled care use. With over a third of all unscheduled care attendances being due to pain and other palliative symptoms, it is possible that targeted interventions to improve symptom control and management could reduce unscheduled care use, minimise distress, and provide timely relief without the delays inherent in attending unscheduled care. Prescribing in the last year of life is an important modifiable risk factor for increased unscheduled care use. Future interventions should target anticipatory care planning, and Just in Case and breakthrough medication provision.