Joint statement: Community-based prescribing for COVID-19 symptoms
On 3 April, National Institute for Health and Care Excellence (NICE) produced a rapid guideline on managing coronavirus (COVID-19) symptoms (including at the end of life) in the community. This includes advice on managing symptoms of breathlessness.
It is vital that dying patients are given as much dignity and comfort as is possible. To that end, the guideline recommends considering an opioid and benzodiazepine combination for patients with coronavirus who are dying, are distressed and suffering moderate to severe breathlessness.
These drugs do not currently have a UK marketing authorisation for this use. We know that some clinicians are worried about how this guideline fits with GMC and MHRA advice about the use of medicines that are unlicensed or outside the terms of their existing license (‘off-label’).
We want practitioners to know that it is entirely appropriate to follow these guidelines and that we would not have concerns about prescribing decisions based upon them.
These are permissive guidelines and doctors should use their judgment about what is right for the patient in front of them, including on appropriate dosage. Should these drugs be unavailable, clinicians can also use their judgment and available evidence to work outside these specific recommendations and make decisions based on what is best for their individual patient.
- GMC prescribing guidance is clear that you may prescribe unlicensed medicines where this is necessary to meet the specific needs of the patient and there is sufficient evidence or experience of using the medicine to demonstrate its safety and efficacy. You must give patients (or their carers) sufficient information about the medicines you propose to prescribe to allow them to make an informed decision. You must always answer questions from patients (or their carers) about medicines fully and honestly.
- GMC end of life care guidance is clear that you 'must also give early consideration to the patient’s palliative care needs, and take steps to manage any pain, breathlessness, agitation or other distressing physical or psychological symptoms that they may be experiencing, as well as keeping their nutrition and hydration status under review.'
Providing dying patients with as much comfort and dignity as possible is essential. For end of life care, the NICE guidance is clear that sedation and opioid use should not be withheld through fear of causing respiratory depression.
We welcome NICE’s guidelines and support clinicians in using their judgment to apply them to treatment decisions for their patients. These are extraordinarily challenging times for patients, their families and for the clinicians trying to provide high quality end of life care.
Further resources are available on the GMC’s ethical hub, the from the CQC, the British Medical Association, Care Provider Alliance and Royal College of General Practitioners, the and the MHRA guidelines on when medicines are off-label or unlicensed.