PRESCRIBING

«  Good prescribing is a skill.

«  The single most important step in prescribing is the routine use of a drug card. 

— Drug Card —
Cynthia Spencer House

(Sample shown here is reduced)

The drug card lists medications, and gives times each drug should be taken, together with the purpose of each. It should be filled in with the patient, and with his carers. It should be explained clearly and reviewed regularly with them. Any changes to the patient’s medications should be noted clearly on the card. The drug card also improves communication about the patient’s current medication among team members. Ask the patient to bring the card to all appointments.

It is important to ask about drug preferences when prescribing new medications. Many patients have already tried a variety of pills and potions, and have developed strong feelings about some of them.

Consider the best route for each drug - oral, sublingual, by suppository, continuous subcutaneous infusion, or IM injection. (IV drugs are rarely, if ever, necessary.)

Carers often like to know how much flexibility they can have. (For example, can they increase the analgesics?) They need to know which drugs are essential, and what to do if the patient is vomiting and unable to take them orally.

Review regularly. In good hospice practice the drug orders for the patient are reviewed every day by doctor and nurse together.

It is a good principle to make only one drug change at a time, so that if changes occur (for better or worse) it is possible to pinpoint which treatment has been responsible.

It is important to stop unnecessary medications whenever possible. For example, some patients have been on anti-hypertension medication for years, and this may become inappropriate. Similarly, patients are usually willing to stop unnecessary iron tablets because of their constipating effect.

«  Stop drugs that have not helped.

Most patients have several symptoms and polypharmacy is unavoidable.

Always explain any drug changes. It is distressing to patients if medications change without explanation.

Be flexible. Treatments may need to be changed if priorities change.

Do not use prescribing as a barrier. When patients complain of anxieties it can be tempting to prescribe drugs when what is often needed is a sensitive discussion of their true situation.

Patients sometimes blame the drugs for the weakness or drowsiness of advanced disease. Changing drugs can sometimes be the doctor’s excuse to avoid discussing the difficult issues of dying.

“In the practice of our art, it often matters little what medicine is given, but matters more that we give ourselves with our pills.” (Alfred Worcester, The Care of the Aged, the Dying and the Dead, 1935)

The author and publisher have taken precautions to ensure that the information in this book is error-free. However, readers must be guided by their own personal and professional standards of good practice in evaluating and applying recommendations made herein. The contents of this book represent the views and experience of the author, and not necessarily those of the publisher.