Anticipatory syringe drivers: a step too far.

The recent Gosport War Memorial Hospital inquiry1 has increased UK patient, public and clinician awareness about syringe drivers for continuous subcutaneous delivery of opioids and other medications at the end of life.2 3 The inquiry found that at least 456 patients died where opioids had been prescribed and administered in unjustified doses, commonly via syringe drivers. In safe hands, syringe drivers facilitate appropriate and effective control of pain and other symptoms for patients who are no longer able to swallow or absorb oral medication, commonly when close to the end of life. The Gosport findings highlight the importance of ‘safe hands’. In an overstretched clinical climate in which clinicians are encouraged to plan ahead to optimise patient care, Gosport is a timely warning of the potential dangers of ‘anticipatory syringe drivers’ prescribed in anticipation of future symptoms at the end of life.

The anticipatory prescribing and administration of opioids in Gosport hospital was highly anomalous and did not reflect standard palliative care practice. A serious category error was common; most people were in hospital for rehabilitation and were not terminally ill. The inquiry underlined that opioid delivery to the wrong people, at the wrong time, in the wrong doses, hastened many deaths. These unacceptable practices highlight the risks of prescribing anticipatory syringe drivers (along with excessive starting doses or wide dose ranges) to be started by third parties whose clinical assessment skills are unknown to the prescriber. This can result in syringe drivers being started, or doses increased, without skilled assessment and consideration of potentially reversible causes of symptoms and clinical deterioration.

Anticipatory prescribing of injectable drugs ahead of need is regarded as best practice for the dying in the UK,4 5 ensuring that relevant drugs are available in the home ‘Just in Case’ they are needed for ‘as required’ or pro re nata (prn) injections in the future. There is a danger that this may be conflated with anticipatory syringe driver prescribing. The two should be regarded as distinct interventions. Commencing a syringe driver marks a more significant change in patient care. Syringe drivers should only be prescribed after symptoms have developed, drugs and doses being decided in the light of response to previous injection doses. Once started, it is rare to discontinue a syringe driver, and family members often perceive death occurs soon afterwards.6 7 Before starting a syringe driver, it is vital to explore patient and family understanding and wishes, to discuss the goals of treatment, including the possible effects of administered drugs and to advise that drugs given in doses appropriate for symptom control will not hasten death.8 9 These conversations require the skills of a compassionate, knowledgeable and experienced doctor or nurse.

The authors are aware that on occasions nurses may ask doctors to prescribe an anticipatory syringe driver when it is evident that a patient's condition may deteriorate soon. This can avoid delays in getting drugs prescribed ‘out of hours’ by practitioners unfamiliar with the clinical situation.10 11 Recent local fieldwork by our team found that 2 of 13 general practitioners (GP) interviewed were comfortable with prescribing anticipatory syringe drivers at the end of life. They trusted community nursing colleagues to give these drugs appropriately. Conversely, other GPs thought that syringe drivers should only be prescribed in response to symptoms developing and after a doctor had made a face-to-face assessment to rule out any reversible symptoms.

Guidance from the National Institute for Health and Care Excellence (NICE),4 Healthcare Improvement Scotland5 and the British Medical Association12 lacks clarity about anticipatory syringe drivers. NICE guidance simply advises ensuring suitable anticipatory medicines and routes are prescribed as early as possible.

Recommendations

In the absence of appropriate guidelines, we recommend syringe drivers should only be prescribed after an experienced doctor or nurse prescriber has reviewed the patient in person in order to consider the causes of deterioration and associated symptoms, evaluate reversibility, establish a dying diagnosis and appraise the effectiveness of previously administered prn drug injections. There is also an urgent need for research to guide safe and effective practice in this area.