Guidelines For The Handling Of Palliative Care Medicines .
Guidelines forthe handling ofpalliative caremedicines incommunityservicesVersion 2, June 2020
These guidelines have been developed as a partof the caring@home project and are endorsed byPalliative Care Australia. They represent a consensusbased approach to the handling of palliative caremedicines by community services, and considerjurisdictional legislative requirements, policies andguidelines across all Australian states and territories.ACKNOWLEDGEMENTcaring@home and NPS MedicineWise would like toacknowledge the many people and organisationswho have contributed their time and expertise inthe development and review of this document. ACT: ACT Health Protection Service ACT: Calvary Healthcare QLD: Medicines Regulation and Quality,Queensland Department of Health NSW: NSW Poisons Information Centre NT: Medicines and Poisons Control, NTDepartment of Health SA: Medicines and Technology Programs,Department of Health and Wellbeing, SA Health Tasmania: Department of Health and HumanServices VIC: Drugs and Poisons Regulation, Department ofHealth and Human Services WA: Medicines and Poisons Regulation Branch,WA Department of Health National: Palliative Care AustraliaCopyright 2020 Brisbane South Palliative Care Collaborative and NPS MedicineWise.This document was accurate at the date of publication and date of any subsequent re-publication.It is the responsibility of each authorised person, designated person and health professional to ensurethat they meet their legal obligations. Commonwealth, State and Territory legislation is subject to changeat any time so readers are advised to check current legislation. For these reasons NPS MedicineWise andBrisbane South Palliative Care Collaborative do not guarantee, and accept no legal liability arising from orconnected to, the accuracy, reliability, currency, completeness of any material contained in these guidelines.2 caring@home
CONTENTS1.INTRODUCTION. 52.STATE VARIATIONS. 63.GLOSSARY OF TERMS. 74.COMMUNITY SERVICE PROVIDERS. 84.1. Medicine management.84.2. Medicine storage.8PART A: SERVICES THAT ADMINISTER PATIENTS’ OWN MEDICINE.84.2.1.Storage: All medicines. 84.2.2. When a patient needs to take medicine away from home. 84.2.3. Individual responsibility for medicine storage and security. 84.2.4.Individual disposal of medicine. 8PART B: SERVICES WITH HEALTH SERVICE APPROVAL.94.2.5.Service responsibility. 94.2.6.Ownership of medicine . 94.2.7.Security: Schedule 8 medicines within the confines of the service. 94.2.8.Storage: Temperature-dependent medicines. 104.2.9.Stock rotation. 104.2.10. Service disposal of medicine. 104.2.11. Emergency medicine for home visits. 114.2.12. Transport . 114.3. Acquisition of stock medicine. 124.4. Prescribing. 134.4.1.Medicine authorisation. 134.4.2.Emergency telephone orders. 134.5. Medicine administration. 144.5.1.Who can administer?. 144.5.2.Transcribing. 164.5.3.Procedure for administering medicine. 164.5.4.Reconstituting. 164.5.5.Nurse-initiated stock medicine (single-dose only). 17Guidelines for the handling of palliative care medicines in community services 3
4.6. After-hours emergency situations. 174.6.1.Drug register. 174.6.2.Witness to administration and discarding of a patient’s own medicine. 194.6.3.Balance checks. 194.6.4.Loss or theft of a Schedule 4 or Schedule 8 medicine . 204.6.5.Destruction of unusable Schedule 8 medicines . 214.6.6.Loss of a drug register. 214.7. Dose administration aids. 224.8. Complementary and alternative medicines (CAM). 224.9. Adverse drug reactions (ADRs). 224.10. Medication errors . 234.11. Subcutaneous infusion devices. 234.11.1. Storage of subcutaneous infusions. 24Appendix A State and territory medicines regulations.25Australian Capital Territory. 25New South Wales. 25Northern Territory. 25Queensland. 25South Australia . 25Tasmania . 25Victoria . 25Western Australia. 25Appendix B Contact details for state and territory regulators.26Appendix C Australian/New Zealand standard ‘User-applied labels foruse on syringes containing drugs used during anaesthesia’.27Appendix D Medicine information to prevent product degradation.28References.29NOTES.314 caring@home
1. INTRODUCTIONMany patients receiving palliative care wishto remain at home for as long as possible. Tohelp achieve this aim, they need rapid access tomedicines to provide symptom relief. If symptomrelief is not achieved, patients may need to presentto their local emergency department and thiscan result in unwanted admissions to acute carefacilities and poor patient outcomes.Community service providers recognise theneed for patients receiving home-basedpalliative care to:The guidelines may be used by community serviceproviders to develop detailed protocols andprocedures tailored to the requirements of theirindividual service or facilities. Such protocols andprocedures support health professionals in thepractice of handling and administering medicine topalliative care patients living at home.These guidelines have been developed as part ofthe caring@home project.1. have their independence and quality oflife maximised – this includes optimalpharmacological management of symptomsrelated to their disease processes2. remain at home for as long as is desired and/or possible3. be provided with suitable support, includingsupport for their carers, to enable theirwishes to be fulfilled.This document presents consensus-based bestpractice for the handling of medicines by individualsand staff of community service providers.Guidelines for the handling of palliative care medicines in community services 5
2. STATE VARIATIONSAs part of the development of these guidelinesstate poison regulations were reviewed and expertadvice was sought from state poisons departments.Similarities and differences between states werenoted and state variations are listed withineach section of the guidelines. We would like toacknowledge all the state poisons departmentswho took part in the development of theseguidelines. It is recommended that communityservice providers refer to the poisons regulationslisted in Appendix A State and territory medicinesregulations and Appendix B Contact details for stateand territory regulators for further guidance on thesafe handling of medicines in their state.6 caring@home
3. GLOSSARY OF TERMS adverse drug reaction – a noxious and unintended palliative care – care provided for a person ofresponse to a medicine that occurs at dosesnormally used in humans for the prophylaxis,diagnosis or therapy of disease, or for themodification of physiological function. authorised person – a registered healthprofessional authorised to possess, administer,supply, dispense or prescribe a medicine. carer – a person who provides personal care,support and assistance to another person who hasa disability, medical condition or mental illness, orwho is frail and aged. cytotoxic medicine – a medicine that is toxic tocells. designated person – a person who has beendesignated by the community service provider toperform a specific duty within the palliative caresetting. dose administration aid – a device wheremedicines are stored and divided into containersaccording to an administration period. drug register – a register or administration bookto record the receipt, administration and any othertransaction of all Schedule 8 medicines that arestored at the service. health professional – a person who providespreventive, curative and promotional care with theaim of meeting the health needs and expectationsof populations and individuals. Also known ashealthcare practitioner, healthcare professional. imprest stock – medicines supplied from a hospitalor authorised poisons seller to establish andmaintain a stock of medicines for use elsewhere. medical practitioner – a physician (doctor). medication order – a written order by anany age who has a life-limiting illness, with littleor no prospect of cure, and for whom the primarytreatment goal is quality of life. person responsible – the person who has theauthority to make healthcare decisions on behalfof a patient whose ability to make decisions ispermanently or temporarily impaired. The personresponsible can consent to most healthcare issues. Poisons Standard – legislation regarding theclassification of medicines or poisons available inAustralia into Schedules. prescriber – a health professional authorised towrite prescriptions and medication orders and givedirections (verbal or written) about administrationand supply of prescription-only medicines. Schedule 4 medicine – also known as prescriptiononly medicine. Schedule 8 medicine – also known as a controlleddrug is a medicine with a higher risk of abuse anddependence, classified by the Poisons Standard.Also known as a drug of dependence, controlledmedicine, controlled poison or narcotic substance. scheduled medicine – a medicine that is scheduledunder the national classification system (PoisonsStandard) according to the level of regulatorycontrol over the availability of the medicinerequired to protect public health and safety. stock medicine – a medicine that has not beenindividually supplied for a specific patient (forexample, by a pharmacist on prescription). substitute decision-maker – a person appointedor identified by law to make health, medical,residential or other personal decisions on behalfof a patient whose decision-making capacity isimpaired.authorised health professional for a medication tobe dispensed by a pharmacy for administration to a transcribing – the process whereby someoneother than the authorised prescriber writes onpatient.a medication order to direct the subsequent medication record – a written history of orders foradministration of medicine to a palliative carethe administration of medicines to a patient.patient. own medicine – the patient’s prescription or overthe-counter medicine.Guidelines for the handling of palliative care medicines in community services 7
4. COMMUNITY SERVICE PROVIDERSCommunity service providers may use theseguidelines to develop detailed protocols andprocedures tailored to their individual serviceor facilities.4.1.Medicine managementA multidisciplinary approach to the developmentof policies, procedures and medicine managementprocesses within an organisation is advisable. Thisapproach may be applied to: the development and approval of writtenmedicine policies and procedures the rationalisation of medicine use in relationto efficacy, safety and cost the analysis of medicine incident reports any recommendations concerning the ongoingeducation of staff any recommendations concerning qualityactivities relating to medicine administration.4.2.Medicine storagePART A: SERVICES THAT ADMINISTERPATIENTS’ OWN MEDICINE4.2.1.Storage: All medicinesAdvise patients and their carers that, to ensuremedicine safety and effectiveness, appropriatestorage is important. Medicines should be storedaccording to the instructions on the label.Generally, medicines are stored in their originalcontainer in a cool, dry place. The stability andeffectiveness of some medicines depends on correctstorage temperature – for example, those medicinesrequiring refrigeration.Patients and carers who require assistance withmedicine management may also need help to storemedicines in a safe manner – for example, out ofreach of children.8 caring@homeSome patients and carers may be unable to reador understand medicine labels and instructionsbecause of minimal reading skills, low health literacyor limited English proficiency. These people mayneed more help with medicine management andsafe storage.4.2.2. When a patient needs to takemedicine away from homePatients should be advised on appropriate storageand transport. For example, medicines normallystored in the fridge can be put in a portable iceboxor insulated box with a cooler block. Keep thetemperature between 2 C and 8 C during transport.4.2.3. Individual responsibility for medicinestorage and securityInform patients and carers that they are responsiblefor safe storage of all medicines in their home.4.2.4.Individual disposal of medicineMedicines should be disposed of safely and in a waythat is not harmful to the environment. Unwantedand expired medicines should be returned tocommunity pharmacies, most will be disposed ofvia the Return Unwanted Medicines (RUM) project,which provides a free and safe method for disposal.Individual services should develop guidelinesfor the disposal of patient medicines and for thedisposal of a patient’s own stock of medicinesafter obtaining consent from the patient. Seesection 4.2.10 Service disposal of medicine for moreinformation on the disposal of medicines. Theseguidelines can be adopted from Guiding Principlesfor Medicine Management in the Community.1, 2
4.2.6.PART B: SERVICES WITH HEALTHSERVICE APPROVAL4.2.5.Service responsibilityThe service manager or other designated personhas overall responsibility for the storage of allmedicine at the service. If the manager is nota registered nurse, this responsibility may bedelegated to a specified senior nurse or nursingposition (designated nurse) depending on stateor territory law. This authorised person shouldensure that correct storage conditions are met, inrelation both to the legislation and manufacturerrecommendations.State and territory variations:Service responsibilityWestern AustraliaIf scheduled medicines are stored as impreststock, a permit is required. The permit holdermust be registered through the AustralianHealth Practitioner Regulation Agency(AHPRA) and have authority to possess andadminister scheduled medicines under theMedicines and Poisons legislation. See theMedicines and Poisons Act 2014 for furtherinformation.Ownership of medicineUsing one patient’s own medicine as stock medicinefor other patients is illegal, even if the medicine hasbeen returned or donated to the organisation.4.2.7.Security: Schedule 8 medicines withinthe confines of the serviceStorage of Schedule 8 medicines may dependon the number of doses to be stored and shouldcomply with state and territory legislatedrequirements. Schedule 8 and Schedule 4 medicinesare stored in a secure container that is not accessibleto members of the public and is locked when notin use. The key or combination to the container iskept in the possession of the authorised person atall times.The container should comply with the requirementsof the relevant state or territory legislation, asoutlined below.State and territory variations:Service responsibilityAustralian Capital TerritoryStorage requirements
Guidelines for the handling of palliative care medicines in community services 5 . 1. INTRODUCTION. Many patients receiving palliative care wish to remain at home for as long as possible. To help achieve this aim, they need rapid access to medicines to provide symptom relief. If symptom rel
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