Corticosteroid Prescribing in New Zealand Palliative Care Settings

• Main Author: Denton, Anne Paton
• Other Authors: Shaw, John
• Published: ResearchSpace@Auckland 2012
• Online Access: http://hdl.handle.net/2292/18013

Background Modern palliative care developed in the 1960s in response to the perceived overmedicalisation and lack of recognition of the plight of the terminally ill patient. The development of evidence-based practice for palliative care has been slow and not without its difficulties because clinical trials involving vulnerable dying patients have been problematic. Prescribing in palliative care does appear to be different from other medical specialities; an example of this is the prescribing of corticosteroids. Corticosteroids are a potent group of medicines, with many adverse effects, that are widely prescribed as adjuvant drugs in palliative care for both specific and non-specific indications. On initial impression, little of their prescribing appears to be supported by rigorous evidence. This study was commenced with a desire to find out more about these medicines and what influences their prescribing in the palliative care setting. Aim and objectives The aim of this study was to explore and clarify the reasons for the prescribing of corticosteroids in New Zealand palliative care settings. Objectives included the identification of which corticosteroids were prescribed, as well as their indications, doses, use of guidelines, and processes for their reviewing and monitoring. The perceptions of those involved in the prescribing of corticosteroids were also sought. Methods A mixed methods approach was undertaken to include a quantitative phase (Phase One) and qualitative phase (Phase Two). Phase One was a retrospective review of inpatient use of corticosteroids in a sample of six New Zealand hospices. These hospices were chosen to give a representation of corticosteroid prescribing during the chosen year of 2007. Phase Two consisted of semistructured interviews with key informants (prescribers and senior nurses) from the six hospices and was intended to elicit information on factors influencing the use of corticosteroids in those hospices. Results In Phase One, the case notes of 1179 inpatients in the six hospices were reviewed and data was recorded of those who had been prescribed corticosteroids. There was a marked consistency of between 61% and 69% in the proportion of patients prescribed corticosteroids in the sample hospices. Corticosteroids were prescribed most commonly for non-specific reasons, and despite prescribing being similar in dose range and choice of corticosteroid, it varied in course length, method of stopping, recording of monitoring and reviewing, and recording of adverse effects. In Phase Two, 18 key informants were interviewed (12 medical practitioners and six senior nurses). Interviewees were shown the data pertaining to their hospice from Phase One of the study. Interviewees agreed that there were a number of challenges associated with these frequently prescribed medicines. They suggested that there was lack of formal evidence behind their corticosteroid prescribing and voiced surprise and disappointment over the amount of nonspecific prescribing, methods of stopping corticosteroids, monitoring and reviewing, and lack of recording of adverse effects. Discussion As evidenced in this study, corticosteroids are widely prescribed as adjuvant drugs in palliative care, most commonly for non-specific indications. The corticosteroid of choice in this study was dexamethasone. Monitoring and reviewing of these medicines was under-recorded and adverse effects, if recognised, were generally not recorded. By exploring clinicians��� practice and perceptions of prescribing and comparing this with existing articles and guidelines, it was found that these potent commonly prescribed medicines tended to be used experientially and intuitively. Corticosteroid prescribing appeared not to be supported by rigorous evidence. These findings seem to be consistent with the limited international literature in this area and suggest that it is timely for a reappraisal of their use in palliative care.