Over the last several months, I’ve conducted interviews with more than forty participants for my PhD study on a very special area within palliative and end of life care – anticipatory prescribing in care homes. The engagement we saw and felt during the recruitment and interview period was incredible, and I’m grateful to everybody involved. That being said, the transition from interviews to coding to thematizing to writing up chapters has proven both conceptually and practically challenging. I’m just finishing off a first chapter chronicling the burdens experienced by the health and social care professionals during the anticipatory prescribing (AP) process (the prescribing, procuring, dispensing, administering, monitoring, storing, disposing of anticipatory medications). I’m drawing on the work of Zarit and colleagues (1985) with the hope of cataloguing, exploring, and perhaps (one day) alleviating the practical and emotional tolls that the various elements of the AP process take on a workforce that is already stretched so thin.

I’m also exploring the bureaucracy inherent to AP processes; the tedium of it all, simply put. It seems that CHMs and staff members often conceptualise the rules and regulations and recommendations as necessary evils, especially in the areas of storage, monitoring, and disposal of AP meds. I’m also interested in the relationship between communication, documentation, Being-in-the-workplace (in a Heideggerian sense…documentation can work to tether a worker to their workplace.) Bureaucracy can confer a sense of ontological security in work, but it can also render the work frustrating or mundane. Our interviewees have talked about the monitoring, storage and disposal of AP meds in many ways, but most commonly, they’ve framed them as both a necessity and an administrative burden.

Most all bureaucracies are saturated with networks. In healthy bureaucracies, those networks facilitate communication and positive relationships. There is a relational aspect to prescribing and administration that the interviews have made clear, particularly at the heights of the COVID-19 pandemic when GPs would not enter care homes and nurses provided assessments and recommendations for medicines. When bureaucracies and networked relationships are good and robust, nurses and care home managers are comfortable telling their GPs, ‘Mrs. Smith is deteriorating. She may need anticipatories, for the weekend’, and the GP is often happy to come in, assess Mrs. Smith, and prescribe accordingly. Other CHMs have described poor relationships with GPs resulting in few to no anticipatory prescriptions for their residents. Beyond that, strong networks are conducive to health care professionals coming together (nurses, care home managers, care home owners, GPs, consultants, pharmacists, and paramedics) and reflecting on issues over tea that they experienced, such as the deep trauma following a difficult care home death, resulting from a paramedic’s​ legal incapacity to administer end of life controlled drugs, despite morphine being in the ambulance. That collective reflection is a strong foundation for a commitment to change, and thus amendments to policy and AP bureaucracy (such as, for example, the introduction of a Patient Group Direction allowing for paramedics to administer anticipatory medications).

Several other chapters will come out of this study focused on findings relating to the language that professionals deploy in describing AP to one another (and how that differs when talking to residents and their families), and decision-making at the point of prescribing and administration (as well as the risks that accompany both processes). It has been a wondrous, challenging experience, learning from and writing about the people who not only work in the spaces that so many prefer to not think about, but who go so far beyond the call of duty to see them and their residents improve.

This study is funded by the Abbeyfield Foundation.

Team members include:

Megha Majumder, PhD Student in the Palliative and End of Life Care Group at the University of Cambridge

Professor Stephen Barclay, University Senior Lecturer in General Practice and Palliative Care; General Practitioner; Honorary Consultant Physician in Palliative Medicine. Primary Care Unit, University of Cambridge. Honorary Professor of Palliative and Primary Care, University of East Anglia

Professor Kristian Pollock, Professor of Medical Sociology, University of Nottingham

Professor Claire Goodman, Professor of Health Care Research at the Centre for Research in Public Health and Community Care, University of Hertfordshire