Nasal fentanyl and buccal midazolam carer administration ‘as needed’ for breakthrough symptom control in a specialist palliative care unit: a nested qualitative study

Introduction: When people are dying and unable to take oral medication, injectable medication is commonly used, usually administered by healthcare professionals. There may be delays to symptom relief due to travel to the person’s home. In a randomised controlled trial (RCT) previously reported, nasal fentanyl (NF) or buccal midazolam (BM) were administered by lay carers in a hospice. Objective: (1) To report experiences of lay carers who administered NF and BM for symptom control and (2) To use feedback to develop guidance informing a future definitive RCT to determine whether NF and BM administered by lay carers can lead to timely, improved symptom control for people dying at home and fewer ‘emergency’ community nursing visits than standard breakthrough medication administered by healthcare professionals. Material and methods: Semistructured interviews with lay carers who gave trial medication were conducted. Interview data were analysed using a stage by stage method to code and categorise transcripts. Findings: The six themes were: (1) Participation—lay carers welcomed the opportunity to administer medication; (2) Ease of use—lay carers found preparations easy to use; (3) How things could have been done differently—lay carers would have liked access to trial drugs at home; (4) Training—lay carers were happy with the training they received; (5) Timing—lay carers liked the immediacy of trial drugs and (6) Evaluation—assessing symptom intensity and drug efficacy. Conclusions: Participation was acceptable to patients and lay carers, and beneficial for symptom relief. The findings will inform planning for a future community-based study.