• Extended nurse prescribing in palliative care

Mula C and Ware S. Extended independent nurse prescribing in palliative care. Nursing Times 2003; 99(18): 30-32

These authors argue that for holistic, seamless palliative care to be offered to patients, further developments are needed. One is that nurses must be licensed to prescribe across the whole British National Formulary including unlicensed medicines and opioids (see news article for details of recent government proposals to extend the list of drugs that can be prescribed by extended formulary nurse prescribers in palliative care to include some controlled and ‘off-label’ drugs). Extended formulary nurse prescribers should receive financial recognition, pharmacists should collaborate across all settings, ongoing clinical supervision must be available, continuing professional development should be compulsory, and commissioners of trusts must be committed to supporting nurse prescribing in palliative care.
Palliative care nurses have traditionally advised doctors on medication regimes and extended prescribing offers these specialist nurses the opportunity to formalise this practice and work more autonomously. The situation for nurses prescribing from the other three current categories (minor injuries, minor ailments, health promotion) of the Nurse Prescribers Extended Formulary (NPEF) is rather different.

Prescribing in palliative care often involves making complex decisions, with no clear right or wrong answers. The ability to prescribe appropriately and immediately in response to patients’ needs will reduce distress for patients and carers.
However, many drugs routinely prescribed in palliative care are not currently on the NPEF. Controlled drugs, in particular, can only be prescribed by doctors, although they are often following the advice of specialist palliative care nurses. Furthermore, 25% of all prescriptions in palliative care are for licensed drugs used for unlicensed indications or given by an unlicensed route; at present, nurse prescribers cannot prescribe drugs beyond their license.

Another possible limitation is that it may not be easy to find enough suitable medical practitioners who can supervise the learning in practice element of the training and offer appropriate support to nurses practising at advanced and specialist level.

The authors also question whether the 12 days of learning in practice are sufficient to equip nurses with the skills to perform clinical examinations. Some nurses have developed these, working closely with their medical supervisor, for example in the diagnosis of bowel obstruction.

The authors’ personal experience since they started prescribing from the extended formulary has been that the system has been received favourably by patients, carers and health professionals. They have been able to address patients’ symptoms sooner than if they had to wait to be seen by a doctor. It has been agreed locally that the nurse prescriber should discontinue medications not in the formularies when they are no longer indicated on the drug regime. From the legal point of view, they point out that nurses need to make sure that their contract of employment is updated to included extended prescribing, thus ensuring that their employer carries vicarious liability for their actions when undertaken as part of their nursing duties.

Effective communication networks are essential between doctors and prescribers to avoid duplication or omissions, particularly as the assumption of greater responsibilities by nurses may lead to less contact between doctors and patients. Nurses working in the community face a particular challenge as access to patients’ records may be limited and telephone contact is not always possible. Nurse prescribers should, however, only prescribe when the information available is sufficient and adequate and should do everything they can to obtain full access to patients’ records before prescribing. Electronic records and prescriptions may ease some of these difficulties.

Further developments are necessary if the objectives of extended prescribing are to be met and palliative care specialists must make their views known, lobby for an improved formulary and share experiences.

Website: Nursing Times