Results of Phase 1  We searched four electronic databases to identify previous studies that looked at prescribing practices for adult patients (≥18 years) receiving palliative care for any life-limiting illness in any setting. Fifty-six studies met our inclusion criteria.

Prescription Trends: This review showed that the average number of prescribed medicines per patient ranged from 3 to 23. Typically, prescribing changes involved decreases in medicines for existing long-term condition and increases in medicines for symptom relief closer to the time of death. However, less than 50% of the studies assessed whether the medicines that patients received were appropriate. These studies reported that 15-92% of patients were receiving a medicine that may not have been appropriate.

Phase 1 – Conclusion: This review provided a broad overview of existing research and showed that many patients receiving palliative care receive multiple medicines closer to the time of death. The review includes recommendations for future research and the full-text review article [1] is freely available in Exploratory Research in Clinical and Social Pharmacy (link to paper).

Results of Phase 2  We used the literature review findings to help inform the development of draft guidance for identifying potentially inappropriate prescribing of medicines for the relief of symptoms commonly experienced by older adults with cancer who are receiving palliative care. This guidance focused on patients with an estimated life expectancy of less than one year.

Developing Prescribing Guidance: The developed guidance, containing a list of 28 recommendations was shared with a group of 18 experts in palliative care as part of a Delphi consensus exercise**.

PIP-CPC recommendations: The final prescribing guidance on identifying potentially inappropriate prescribing of medicines for the relief of symptoms commonly experienced by older adults with cancer who are receiving palliative care contains 24 recommendations. These relate to: anorexia-cachexia (n = 1); anxiety (n = 2); constipation (n = 5); delirium (n = 1); depression (n = 3); diarrhoea (n = 1); dyspnoea/breathlessness (n = 1); fatigue (n = 2); insomnia (n = 2); nausea and vomiting (n = 2); pain (n = 3); duplicate drug classes (n = 1).

Phase 2 – Conclusion: A consensus-agreed set of prescribing recommendations was developed for identifying potentially inappropriate prescribing of medications for symptomatic relief in older adults with cancer who are receiving palliative care and have an estimated life expectancy of less than one year. The full-text article [2] is freely available in the Journal of Geriatric Oncology (link to paper).

** The Delphi consensus exercise is a method used to arrive at a group opinion or decision. Experts respond to several rounds of questionnaires, and the responses are gathered and shared with the group after each round. The experts have an opportunity to adjust their answers after each round, based on how they interpret the “group response” provided to them. This approach allows for a true consensus of what the group thinks

Results of Phase 3  We looked at the types of medicines that have previously been prescribed to a sample of older adults with cancer using historical information from a palliative care centre. We tried to determine whether prescribing practices followed the recommendations that were developed in Phase 2.

Applying the guidelines: Of the 24 recommendations developed in Phase 2, only four could be applied. This was due to a lack of additional information available in patients’ notes, mainly in terms of why a medicine had been prescribed or the date of on which a medicine was first started. Based on these four criteria, the prevalence of potentially inappropriate prescriptions ranged from 0-30%. No patient received oral liquid paraffin as a laxative (recommendation 3.3) or a drug known as a monoamine oxidase inhibitor for depression (recommendation 5.3). Of the patients prescribed opioid painkillers (n=180), 30% (n=54) did not receive a laxative (recommendation 3.4). Of the patients using non-steroidal anti-inflammatory drugs (e.g., ibuprofen) together with corticosteroids (n=53), 15.1% did not receive a drug to protect the stomach such as a proton pump inhibitor (recommendation 11.3).

Phase 3 – Conclusion: This study reports on the first application of the PIC-CPC criteria to clinical records for older adults with cancer who were receiving palliative care prior to death. The study highlighted the challenges in retrospectively applying the criteria using historical data.

Overall Conclusion & Recommendations:

Criteria for identifying potentially inappropriate prescribing of medications for symptomatic relief in older adults with cancer have been developed and undergone consensus validation using the Delphi technique.

• The scoping review (Phase 1) has provided a broad and comprehensive overview of observational studies examining prescribing in palliative care. The review shows that many patients with palliative care needs receive considerable numbers of medications, including preventative medications that may provide limited or no therapeutic benefit closer to death. A limited number of studies examined the appropriateness of prescribing or the potential for harm. The review has generated important recommendations for future research such as the inclusion of assessments of prescribing appropriateness using tools that have been developed specifically to guide prescribing in palliative care, as well as assessment of the appropriateness of medications to relieve common symptoms experienced by palliative care populations towards the end of life.
• The Delphi study (Phase 2) enabled development and consensus validation of the PIP-CPC criteria using an expert panel of palliative care clinicians. The PIP-CPC criteria consist of 24 criteria for identifying potentially inappropriate prescribing of medications for symptomatic relief in older adults with cancer who are receiving palliative care and have an estimated life expectancy of less than one year.  
• The retrospective cohort study (Phase 3) enabled the initial testing of the application of these criteria using clinical records for older adults with cancer who are receiving palliative care.

The study highlighted the challenges in retrospectively applying the criteria using historical data. Future research is needed to facilitate implementation of the PIP-CPC criteria into clinical practice and examine the impact on patient outcomes.