Anticipatory prescribing (AP) of injectable medications to manage common symptoms experienced at the end of life (EoL) is recommended practice (National Institute for Health and Care Excellence (NICE), 2015). AP was initially developed to fix healthcare workflow difficulties and enable ready access to medications, especially during out-of-hours periods. It is now a widespread key intervention in managing dying at home (Bowers et al, 2020).
The language clinicians use to describe AP influences patients' and families' understanding of the nature, significance and purpose of injectable medications and when they are to be used. Surprisingly, at least 22 terms are used in the UK, including ‘just in case medications’, ‘anticipatory medications’, ‘EoL medications’, ‘gold/grey box’, ‘notfallplan’, ‘pre-emptives’, and ‘standby’.
Even the commonly used ‘just in case medications’ can be interpreted in many ways: in case of what? Should they be given to prevent the person from developing pain? Although the presence of anticipatory medications may be reassuring, it may also raise concerns about the dying experience.
The range of terms used, some of which are vague, comforting euphemisms, highlights the challenges for clinicians in explaining that the purpose is to make the medications available, should they be needed for symptom control at the EoL. Several of the terms seem to conceal, rather than reveal, the purpose of the intervention, being ambiguous references to some form of unspecified ‘back-up plan’ that is obscure to anyone who is not a knowledgeable clinician. This raises questions about how helpful these terms are for informing patients and families about the drugs and plans. Clarity of language and shared understanding are important for knowing when it is appropriate to use anticipatory medications, especially in distressing and rapidly changing situations.
It is not just about the name, although the name helps shape shared understanding (Berger and Luckmann, 1966). Anticipatory prescriptions should be based on an assessment of individualised needs and with the agreement of the patient, wherever possible, and family caregivers (British Medical Association, 2020). This involves a suitably skilled clinician assessing likely needs and responding sensitively to patient and family questions regarding the purpose of the medications and when to access help. Evidence suggests that these conversations can be cursory, and patients may have limited awareness and understanding of these medications and their potential side effects (Bowers et al, 2020). Prescribing is increasingly being carried out remotely during the COVID-19 pandemic (Antunes et al, 2020), although the extent to which this changes the nature and quality of prescribing decisions and discussions is yet to be established.
Unclear terms for AP risk creating misunderstanding and hindering important conversations about what might happen during the dying phase. Unambiguous, consistent and easy-to-explain terms are needed to facilitate discussions over the symptoms potentially arising during the EoL and how patients feel about anticipatory prescriptions as an insurance plan. We recommend the use of the term ‘anticipatory medication’, during a sensitive explanation of what may happen during the dying phase and how the medication can be administered to relieve these symptoms.