The LMC is regularly involved in representing and supporting doctors who have been identified as having "performance" issues. The LMC has identified themes which recur, and this regular feature from our newsletter will highlight these, so that our members can avoid these pitfalls.

Palliative care meetings and reviews

It is good practice to identify when patients are in their last year of life, and to discuss with the patient and their families and carers what their wishes are regarding the end of life period.  This discussion should include discussion about preferred place of dying, wishes regarding active treatment, resuscitation status, and symptom management.   It is important too to regularly review the patient to identify whether the choices that have been made are the same or have changed.  Not reviewing the patient can lead to patients having incorrect pre-emptive plans.

LMC advises that practices should have regular palliative care meetings in which EOL patients can be discussed with the multi-disciplinary team.  These meetings can highlight whether patients require review, and which member of the MDT is most suitable to do this.

Pre-emptive prescribing

When patients are identified as being close to the end of life period it is best practice to provide pre-emptive medications so that the patient has access to symptom relieving medications when required.  These medications should be prescribed with clear instructions for use, and further instructions should be given on the CD1 “gold sheet” so that non-prescribers can administer the medications when required.

Recently there have been occasions when clinicians have not been able to support a patient because pre-emptive drugs are not appropriately issued.  The themes which have been identified are

• Pre-emptive drugs not prescribed
• Pre-emptive drugs prescribed without adequate instructions, such as “as directed”
• CD1 form not completed
• CD1 form not signed
• Pre-emptive drugs out of date

LMC advises

1. Pre-emptive drugs should be issued early to ensure they are available when required
2. Instructions need to be clear; this can be facilitated by having a formulary on the clinical system with detailed instructions for each drug
3. CD1 form should be completed and signed, this can be facilitated by using the CD1 form which is part of the clinical record system
4. Practices and pharmacies/dispensaries should have a method for identifying when a patient’s pre-emptive drugs will go out of date