At the edge of licence (Margaret Hook)

Pharmacists working in palliative care are accustomed to seeing medicines prescribed for unusual reasons, as well as the use of unlicensed medicines. My perspective certainly changed when I became a prescriber. Suddenly I was no longer comforted by shared responsibility — backed up by the Palliative Care Formulary.

While I think carefully about all my prescribing (and dispensing) decisions, the use of off-label and unlicensed medicines gives cause for far greater reflection, not least on the evidence base.

Recently I saw a patient with known liver metastases but an unknown primary cancer who was admitted for a week’s respite in the hospice. At her admission check-up, diagnoses of irritable bowel syndrome and Vitamin B12 deficiency were established. Among her current problems were abdominal pain and frequent loose stools, which were “explosive” and sometimes sudden in onset, with occasional incontinence, resulting in anxiety and distress. She was unable to describe the stool appearance because she is registered blind.

During her stay we were able to assess her stool type. The nurses reported type 6 stools (according to the Bristol Stool Form Scale) with a pale fluffy appearance and strong odour, and difficult to flush, which led us to suspect steatorrhoea — fatty stools due to fat malabsorption. With an unknown primary we could not understand the cause of her steatorrhoea, but conjectured that reduced pancreatic enzymes might be part of the problem. Creon is licensed for the treatment of pancreatic exocrine insufficiency and is identified in the Palliative Care Formulary Third Edition as a good choice for treating steatorrhoea.

Often in palliative medicine, consideration of the patient’s immediate needs, rather than attempting to understand the disorder and its progression fully, will direct the treatment decision.

Prescribing dilemma

What is my legal position as a prescriber in this situation? Do I need a treatment plan to prescribe as a supplementary prescriber, or am I able to prescribe independently? Helpful pages on the Department of Health website (“Pharmacist independent prescribing FAQ”) make it all clear: yes, I can prescribe and instruct a non-prescriber to administer the medicine, Creon, to my patient.

So what happened to this patient? Well, the Creon worked, combined with a range of other interventions. Her stay in the hospice significantly improved her quality of life and she was able to go home in a much calmer state.

Although working empirically at the “edge of licence” remains a role for inventive and intuitive doctors, I believe my confidence in practising the art of prescribing in palliative care has grown.

 

Margaret Hook is principal pharmacist for St Peter’s Hospice, Bristol