Palliation from the PBS Prescriber Bag

A blog post written by Paul Tait, Pharmacist and PhD Candidate, Research Centre for Palliative Care, Death, and Dying (RePaDD), Flinders University

Timely symptom management allows people in the terminal phase to remain comfortable at home to die. Medicines play an important role in managing symptoms.

The Pharmaceutical Benefits Scheme (PBS) offers a broad range of formulations ensuring that medicines prescribed for people living in the community are both accessible, through the person’s local pharmacy, and affordable. In addition to subsidising dispensed medicines, the PBS funds a limited range of formulations for prescribers to carry with them on home visits. This functionality is called the PBS prescriber bag. It is available for all prescribers providing care for people living in their home or a residential aged care home.

The PBS prescriber bag is particularly useful in managing symptoms or emergencies that present suddenly in the terminal phase. The CareSearch team has recently published a document (183kb pdf) that outlines a range of useful formulations from the PBS prescriber bag for medical officers and nurse practitioners to carry when providing palliative care in the community. Here are five tips to ensure you get the most out of the PBS prescriber bag.

Ahead of time

To carry formulations useful in managing terminal phase symptoms, the prescriber needs to plan. Plan for ordering. Plan for what else to take with them. Plan for securely transporting the medicines.

Specific stationery (a prescriber bag supply order book form) is required to order these medicines, which is available through Services Australia. Only once the book is received can the prescriber order medicines. The book contains monthly order forms which must be signed when completed and given to a community pharmacist for dispensing.

In addition to taking the medicines with you on home visits, here are three essential items to pack:

• Notebook. By law, prescribers need to keep formal records of medicines they have administered, left in the home, or discarded. A notebook should be used to record important details such as the date, the person’s details, and the medicine used.
• Administering equipment. Medicines won’t administer themselves. Take appropriate equipment including needles, diluents, as well as a sharps container. Write down a list of essential items that you take with you on home visits – this will double up as a useful guide for restocking.
• Prescribing resources. For many prescribers, these medicines are used infrequently, so having considered which dosing resources you will need, will be invaluable. The CareSearchgp App is a free resource that can be used offline if necessary. Alternatively, the Palliative Care Therapeutic Guidelines and the Australian Medicines Handbook could be considered if a physical resource is preferred. As well as dosing resources, note down the telephone details of the pharmacies in the area as well as that of the local Specialist Palliative Care Service. They will be useful people to discuss any ‘curly issues’ that you may encounter, while in the home.

By the time you have collated some medicines, a notebook, necessary administration equipment, and any physical texts, you will need something to transport this all to the person’s home. Some prescribers find a small bag on wheels, with a sturdy lock, useful. Remember that prescribers who carry these formulations must take responsibility for their storage. Security is key.

Ordering each month

Because the ordering is limited to monthly, some prescribers schedule to order their medicines on the last day of the month. Hence, if supplies run out earlier than expected the following month, there is some wiggle room to reorder the next supply earlier than planned. All medicines are fully subsidised by the PBS with no cost to the prescriber.

Timely Dispensing

While the formulations from the PBS prescriber bag can be administered immediately, to manage symptoms, it is important to write a prescription for ongoing supplies. The PBS lists an extensive range of medicines which may be prescribed for patients receiving palliative care. These PBS palliative care items allow for larger quantities, without increasing the cost to the family.

It is a good idea to speak with the person’s usual community pharmacist about routinely stocking medicines from the PBS prescriber bag. This will assist the caregiver when you hand them the prescription – ensuring few delays in accessing continuing symptom management. Equally, pharmacists could use the PBS Prescriber bag document (183kb pdf) to guide which medicines to stock. To encourage good stock turnover, pharmacists could use this document to market which medicines they carry, to all prescribers in the area.

Responsible Storage

Prescribers need to take responsibility for the storage of all medicines. Having a secure place in the practice to store them is vital. A locker or filing cabinet will suffice, provided it can be locked securely. The key or combination code is the responsibility of the individual prescriber. Some prescribers also keep their prescription pads in this storage unit, transferring items to something more mobile (e.g. a small luggage bag) when attending to someone at home. Storing medicines with the prescription pad can save on having to carry the medicines home each night. Medicines that are unaccounted for should be reported to the police.

Medication Administration

The subcutaneous route is widely recommended in the terminal phase. While the subcutaneous route provides high bioavailability and quick onset of action, the administration of large volumes can be painful. As such, it is best to limit the volume to 1.5 millilitres. To administer larger volumes, consider administering as two separate injections or via a continuous subcutaneous infusion pump.

In summary, where the person is deteriorating rapidly, the prescriber can use medicines from their PBS prescriber bag supply to manage symptoms quickly, at no cost. It provides a safety net for those who deteriorate suddenly at the end of life. It is not a substitute for a planned approach to care, but it acknowledges that death, like life, doesn’t always run according to plan.