This series takes a detailed look at the domains of the Decision Support Tool. This week we examine the first three descriptors in the Drug Therapies & Medications: Symptom Control domain, to help you assess your or your relative’s “level of need” in this important domain.
Catch up on parts one to Sixteen below!
Following the 2018 revisions of the DST, Drug Therapies & Medications was one of the only domains that did not move, retaining its original place at domain number ten. While it formerly followed Breathing, it now comes after Behaviour. The assessed levels of need in the Behaviour domain range from ‘No Needs’ to ‘Priority’ needs, one of only four domains that include all six possible levels of need.
In any domain with a possible ‘Priority’ level of need, there is potential for an immediate risk to life, should needs not be met or be met improperly. The ‘Priority’ level of need is sufficient to evidence eligibility for NHS Continuing Healthcare funding (CHC), regardless of any other level of need and without examination of the four Key Characteristics.
Needs in the Drug Therapies & Medications domain are perhaps the most straightforwardly health related; medications being prescribed for the management and treatment of an identified health need. Whether the administration of medication by a suitably trained professional is required, depends on the patient’s capacity and ability to take their medication independently, and in the setting of care. The degree of skill required for such administration will depend on the type of medication prescribed, the nature of the prescription (routine or as required), the effectiveness of the medication in managing symptoms, and the degree of risk and potential side effects.
The following clinical factors are relevant to the assessment of needs in this domain:
- Are medications prescribed?
- Are symptoms well-controlled?
- Are there any side effects of the medications?
- Does the person require supervision and/or prompts to take their medication?
- Is the medication administered by a nurse? If so, is this because of the type of medication or the setting of care?
- Is the person compliant with their medication regime?
- What is the risk to the person if medication is not taken as prescribed?
- What is the route of the medication (oral, sublingual, buccal subcutaneous etc.)?
- Is the medication administered via a feeding tube (PEG – percutaneous endoscopic gastronomy)?
- Does the person administering the medication require particular knowledge or skill (e.g., insulin)?
- Does the person experience pain? To what degree?
- Can the person reliably express pain symptoms?
- Is prescribed analgesia effective in managing pain?
- Does pain impact on care in other domains (e.g., mobility, behaviour)?
- Are any medications prescribed on a “PRN” basis (pro re nata = as required)?
The Decision Support Tool provides the following advice to those assessing needs in the Drug Therapies & Medications: Symptom Control domain:
The individual’s experience of how their symptoms are managed and the intensity of those symptoms is an important factor in determining the level of need in this area. Where this affects other aspects of their life, please refer to the other domains, especially the psychological and emotional domain. The location of care will influence who gives the medication. In determining the level of need, it is the knowledge and skill required to manage the clinical need and the interaction of the medication in relation to the need that is the determining factor. In some situations, an individual or their carer will be managing their own medication and this can require a high level of skill.
References below to medication being required to be administered by a registered nurse do not include where such administration is purely a registration or practice requirement of the care setting (such as a care home requiring all medication to be administered by a registered nurse).
Now we’ve outlined the type of things the Multi-Disciplinary Team (MDT) will be considering in this domain, let’s take a look at the descriptors for the first three levels of need. For each level of need, we provide a case study to give you a better understanding of how the descriptors might be applied at your or your relative’s assessment.
|Symptoms are managed effectively and without any problems, and medication is not resulting in any unmanageable side-effects.
Takes medications independently without prompts or supervision
No issues with compliance
Symptoms effectively managed
No side effects
CASE STUDY – NO NEEDS
Mr. X takes his medication independently, as prescribed by the GP.
His medication regime is non-complex and routinely prescribed. He does not complain of any side effects or unmanaged symptoms.
Mr. X does experience pain in the mornings and takes paracetamol as required with good effect.
Simvastatin 10mg tablets take one each day
Paracetamol 500mg tablets one or two to be taken up to four times a day when required
Citalopram 20mg tablets take one each day
Mr. X presents with ‘NO NEEDS ‘ as his symptoms are managed effectively and without any problems, and medication is not resulting in any unmanageable side-effects.
|Requires supervision/administration of and/or prompting with medication but shows compliance with medication regime.
Mild pain that is predictable and/or is associated with certain activities of daily living. Pain and other symptoms do not have an impact on the provision of care.
Requires supervision with, or administration of, medication
May need prompts to take medication
Does not refuse medication
Mild pain which is predictable and does not impact care in other domains (e.g., mobility)
CASE STUDY – LOW
Medication Administration Record (MAR)
Aripiprazole 5mg tablets take half a tablet each day (antipsychotic)
Baclofen 5mg/5ml oral solution take two 5ml spoonful three times a day (antispasmodic)
Clopidogrel 75mg tablets take each day (antiplatelet medicine)
Donepezil 5mg tablets take one tablet at night (Memory enhancer)
Fenbid 5% gel apply to right shoulder up to three times a day
Paracetamol 500mg tablets one or two to be taken up to four times a day when required
Senna 7.5mg tablets take 2 tablets at night for constipation, may be omitted if bowels loose
Sertraline 50mg tablets take one each day
Mrs X is reliant on trained staff for the administration and monitoring of her medication due to cognitive impairment and being a resident in a care home. Mrs X will take her medication from a spoon with either water or juice. Care records indicate she is compliant with her medication.
Mrs X does experience some arthritic pain in the mornings, for which she is prescribed paracetamol and analgesic gel with good effect. She is able to let carers know if she is in pain and pain is not impacting on her mobility or other care domains.
Mrs X presents with a ‘LOW’ level of need as she requires supervision/administration of and/or prompting with medication but shows compliance with medication regime, and she experiences mild pain that is predictable and/or is associated with certain activities of daily living. Pain and other symptoms do not have an impact on the provision of care.
|Requires the administration of medication (by a registered nurse, carer or care worker) due to:
non-compliance, or type of medication (for example insulin), or
route of medication (for example PEG).
Moderate pain which follows a predictable pattern; or other symptoms which are having a moderate effect on other domains or on the provision of care.
Requires medication be administered by a specially trained person
May require medication via feeding tube
May require injections
Medication requires monitoring but is non-problematic
May refuse medications
Moderate pain which follows a predictable pattern and has a limited impact on care in other domains (e.g., mobility)
CASE STUDY – MODERATE
Mr. X is nil-by-mouth, and all his medications are administered to him via his PEG-tube by a registered nurse.
Mr. X is prescribed a non-complex medication regime which is reviewed routinely by the GP every 6 months. There have been no recent changes or titrations.
All Mr. X’s medications are routinely prescribed, and no PRN medication is documented to be used at this time.
The GP undertakes six-monthly blood tests to check phenytoin levels as Mr. X is prescribed this drug long term.
Mr. X is unable to express symptoms of pain and staff use the Abbey Pain Scale to monitor his condition. Paracetamol is administered four times a day with good effect.
Hyoscine butyl bromide 20mg QDS
Jevity Promote liquid feed 1 litre
Paracetamol 1g QDS
Phenytoin 40mls OD
Mr. X presents with a ‘MODERATE’ level of need as she requires the administration of medication (by a registered nurse, carer or care worker) due to: route of medication (for example PEG).
We hope this has helped you to understand the first three descriptors in the Drug Therapies & Medications: Symptom Control domain. Don’t miss Part 2, coming very soon!
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