SHOULD PCNS PRESCRIBE DRUGS IN A HOSPICE HOME PROGRAMME?

Dato Seri Dr T Devaraj Penang Hospice Society

DRUGS IN MODERN MEDICINE 1

Essential component management disease, symptoms, complications Drug Control Authority Registration Safety, efficacy, GMP Classification drugs Over the counter (OTC ) or also known as non-scheduled poisons (NP) accessible to public Need prescription by doctor (Group B) more potent regulated

DRUGS IN MODERN MEDICINE 2

CLASSIFICATION
MIMS - Malaysian Poison Classification Group A Group B - doctor ,dentist, vet Group C - sell, entry Prescription Book

NP - Non-scheduled poisons or OTC

DRUGS IN MINISTRY OF HEALTH

Ministry of Health

Drug Formulary 2008

Guidance on Prescribing A+ - Consultant / Specialist for specific indication A - Consultant / Specialist A/KK - -do- / Family Physician Specialist

B - Medical Officer
C - Paramedical staff C+ - Paramedical staff doing midwifery

IAHPC LIST OF ESSENTIAL MEDICINES FOR PALLIATIVE CARE 2006

Medications for most common symptoms in P C

Pain: mild, moderate, severe

bone, neuropathic, visceral dyspnea terminal respiratory congestion dry mouth hiccups anorexia cachexia depression delirium insomnia fatigue

constipation
diarrhea nausea

terminal restlessness
sweating vomiting List of drugs: Pall Med 2006; 20:647-651

NURSE PRESCRIBERS SCENARIO IN MALAYSIA Rx drugs Hospitals No Clinics - Spt / GP No MOH clinics Yes - MOH group C

MOH GROUP C DRUGS

Drugs listed as C for use by paramedical staff cover all disciplines except respiratory, psychiatry, drugs affecting immune response, haematology/oncology, rheumatology diagnostic MOH group C drugs applicable in PC are antacids, laxatives, paracetamol, B complex, ferrous fumarate, nystatin and some creams

DUNIA DI SANA SINI

PHS - paracetamol, laxatives, vitamins HCA Spore - PCNS have to consult doctor Australia one service PCN does not carry any drugs /consult Dr but PCNs can increase dose paracetamol / laxatives another service PCNs cannot prescribe but can recommend OTC drugs has a N Practitioner in PC Rx opioids, anti emetics India - illegal for nurse to prescribe and same in PC UK - 20,00 nurses and 1500 pharmacists qualified as independent prescribers and can prescribe controlled drugs (23.4.12) Africa some states PCNs allowed to prescribe opioids USA has Nurse Practitioners

MAKING SENSE OF DIFFERING PRACTICE

Practice stems from the local health care situation Factors - morbidity needs, kinds of health professionals available and other resources for health care, health systems, country size

Other factors socio-economic, costs of health care, quality of care

Task shifting - Malaysia has long history of para -medics delivering health care

1 Malaysia clinics have re ignited controversy over task shifting

WMA ON TASK SHIFTING FROM MEDICAL PROFESSION

In healthcare, the term Task Shifting is used to describe a situation where a task normally performed by a physician is transferred to a health profession with a different or lower level of education and training, or to a person specifically trained to perform a limited task only, without a formal health education. Task shifting occurs both in countries facing shortages of physicians and those not facing a shortages. Although task shifting may be useful in certain situations, and may sometimes improve the level of patient care, it carries with it significant risks. . Berita MMA Jan 2010

SPECIALIST NURSING PRACTICE

SOME DEFINITIONS OF EXPERT NURSES advanced practice nurse (APN) nurse practitioner (NP) clinical nurse specialist (CNS) nurse consultant (NC) Think point: multidisciplinary collaborative care between doctors and allied health professionals is better option continuity of care, patient safety, good care the priority

MEDICATIONS WHAT PCNS ENCOUNTER AT INITIAL VISIT

None
Taking on own OTC or even group B On medications from doctor / doctors

Medications can be group C or group B

Varied sources of medications Medication needs can change over time

DRUG USE IN HHP SOME OBSERVATIONS ON PCNS ROLE

Ideal - PCNs consult doctor each time Q practicality, necessity Class of drugs Group B - only by doctor Group C - selected items for urgent use by PCNs Modifications of drugs in use - have standing instructions consult doctor Think point: with no formal training yet of even PCNs moving on to APNs or NPs can only be a pipe dream

Thank you