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Background Anticipatory prescribing of ‘prn’ medication for symptom control is recommended for those approaching the last week-of-life however practices regarding anticipatory prescribing for continuous subcutaneous infusions (CSCI) varies widely. The Gosport Report highlighted risks associated with anticipatory prescribing for CSCI. The Association of Supportive & Palliative Care Pharmacy state the perceived benefit does not outweigh the risks. Methods A network-wide cross-boundary audit was undertaken of the use of CSCIs in patients known to specialist palliative care services. A survey was completed by each service-lead and feedback collated following presentation of results. Results 208 of 347 patients (174 hospital, 49 community, 124 hospice) prescribed medication via a CSCI were recognised as likely to be dying. Drugs prescribed included strong opioids (286) anti-emetics (133), anxiolytics (89), anti-cholinergics (102), anticonvulsants (20) and steroids (6). Median doses of opioids and benzodiazepines were low (e,g, morphine 10 mg CSCI q24h) The CSCI had been prescribed in anticipation in 1/5 of patients across all care settings (hospital 20, hospice 24, community 16). 58% of services/organisations responding to the survey allow prescribing for CSCI in anticipation. Feedback following presentation of results and proposed guideline highlighted two conflicting sets of views and practices: anticipatory prescribing for CSCI as vital to ensure timely symptom control in the dying vs. the view it is unsafe practice, citing incidents/near-misses resulting from lack of clinical assessment of need at the time a CSCI is commenced. This audit reviewed current practice but is unlikely to capture such clinical incidents or ‘near-misses’ where drugs are administered without indication or at high doses. Conclusion There is conflicting practice and opinion surrounding the risks and benefits of anticipatory prescribing for CSCI. This audit did not identify unsafe practice but will not reliably capture incidents or near-misses. Further evidence-based national guidance is required to guide safe practice.

Background In 2014 the family of a woman who died in one of Britain’s best-known hospitals won their legal claim that her rights were violated when a Do Not Attempt Cardiopulmonary Resuscitation (DNACPR) document was completed without her or her family being consulted. A judicial review noted that Article 8 of the Human Rights Act was breached, concluding that there is a duty to consult patients and/or those important to them in relation to DNACPR unless that consultation may result in physical or psychological harm; this is more than just causing distress. Aim Audit practice regarding DNACPR decisions and the discussions surrounding them in a tertiary cancer centre. Methods A retrospective case note review of patients‘ in whom a DNACPR had been placed was conducted in December 2016. Practice was compared against the 2016 Joint Statement, ‘Decisions relating to cardiopulmonary resuscitation’. Results 22 case notes were reviewed in which a DNACPR was completed; 19 due to futility in cases of terminal cancer and 3 due to patient choice. In 3 cases no consultation had taken place. The reasons for this included patient/family declining a discussion and risk of harm. In 4/22 cases there was no documentation of the clinical reasoning for a DNACPR decision. In 1 case the consultation led to potentially avoidable patient distress. In 7 cases the patient lacked mental capacity to participate in a consultation; in 1 case it was felt it would cause too much harm to discuss the decision with their family. Conclusion Patients and those important to them should be made aware of DNACPR decisions and these conversations recorded, including reasons for the decision. This audit however has highlighted ongoing variability in practice. Further training is needed in order to standardise practice and ensure high quality consultations around this sensitive topic are undertaken.