11/13/24, 7\:44 PM Guide | Prescribing in palliative care

Prescribing in palliative care

Table of contents

Introduction

Symptoms such as pain, excess secretions and agitation are commonly seen in patients nearing the end of life.
Anticipatory medications are prescribed in advance, or ‘in anticipation’ of these symptoms developing. This ensures timely
administration, minimising distress and discomfort.
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There are four main classes of anticipatory medication\:
Analgesia\: for pain
Anti-emetic\: for nausea and vomiting
Anxiolytic\: for agitation
Anti-secretory\: for respiratory secretions
This article will cover how to prescribe anticipatory medications for patients nearing the end of life.

Prescribing

Anticipatory medications are prescribed as subcutaneous injections (SC, injected under the skin) as patients nearing the end
of life are often unable to take oral medications. They should be prescribed PRN, or ‘as needed’
, rather than regularly.
When prescribing anticipatory medications, the following details should be included\:
Drug name
Drug dose
Route (SC)
Indication for each medication\: to make it clear which medication should be used for which symptom
Frequency of delivery (e.g. 1 hourly)
Maximum dose in twenty-four hours\: to ensure safe levels of medication are given, this will also prompt regular reviews if a
patient is requiring frequent doses
Unless the patient has previously received the medications, a low dose should be started and titrated up according to
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response.

Managing common EOL symptoms

Choice of medication and starting doses vary depending on several patient factors including\:
Past medical history\: for example, speci
used in frail patients.
Organ dysfunction\: renal and liver dysfunction a
Drug history\: if patients are already on a background opiate their PRN dose should be calculated based on this, rather than
using the dose for an opioid naïve patient
Preferred medications will also vary according to local guidelines. The examples below are based on the NHS Yorkshire and
Humber guidelines.
3,4
Although this article concentrates on anticipatory medications, it is also important to note that other treatments (including
non-pharmacological) may be used in end-of-life care.
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For example, if pain is caused by constipation, bowel care may be appropriate. In addition, non-pharmacological methods are
equally important in managing symptoms, for example, psychological support, considering environmental factors for those
who are agitated and use of fans for breathlessness.
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Pain

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pressure sores.
Pain can be caused by a variety of factors, ranging from disease-related pain (e.g. direct invasion by cancer) to pain from
Assessment
Recognising pain is important, especially if patients are less responsive and therefore unable to articulate symptoms.
Speaking to a family member, carer or sta
behaviour. Changes that might be observed that could indicate pain include\:
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Facial expressions such as grimacing
Verbalisations such as moaning or shouting out
Body movements such as guarding a particular area/part of the body
Autonomic reactions such as increased heart rate or temperature
Examples of anticipatory medications
Common
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Morphine sulphate 1 - 2.5mg SC. Do not repeat within 1-hour, maximum 4 doses in 24 hours
If reduced renal function (eGFR \<50)\: Oxycodone 1 - 2 mg SC. Do not repeat within 1-hour, maximum 4 doses in 24 hours
For patients already on a background dose of opioid medication, the PRN anticipatory dose is generally 1/6 th
of the total
subcutaneous background dose in 24 hours.
Example
Mr Y has been taking 30mg BD slow-release morphine but is now approaching the last days of life and is not able to
swallow his usual medications. This is equivalent to 30mg SC morphine in 24 hours, and the PRN dose would be 5mg SC
morphine (30/6).

Nausea and vomiting

Causes of nausea and vomiting may include constipation, medication side e
hypercalcaemia).
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Examples of anticipatory medications
Haloperidol 0.5 - 1.5mg SC. Do not repeat within 4 hours, maximum dose 3mg in 24 hours.

Agitation

Causes of agitation include pain, medications (side e
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As with pain, detecting agitation in a patient will rely on observing the patient and listening to those who are looking after
them. Signs of agitation may include\:
Fidgeting/moving arms and legs
Confused
Vocalisations
Examples of anticipatory medication
Midazolam 2.5 – 5mg SC. Do not repeat within 1 hour, maximum 4 doses in 24 hours.

Secretions

With reduced levels of consciousness, patients may become unable to swallow or clear their normal respiratory
secretions/saliva, resulting in pooling in the upper respiratory tract.
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This can cause noisy breathing/a rattling noise as air passes over the pooled secretions. O
after the patient that it is not a distressing symptom, as well as repositioning the patient may be helpful.
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Examples of anticipatory medication
Hyoscine butylbromide 20mg SC. Do not repeat within 1-hour, maximum dose 120mg in 24 hours

Syringe drivers

Syringe drivers are small battery-powered pumps used to deliver medications as a continuous subcutaneous infusion (CSCI)
over a 24-hour period.
A syringe containing the appropriate medications is attached to a needle that is placed under the skin (into the subcutaneous
tissue). An area is chosen which is convenient and comfortable for the patient, often the thigh, upper arm or abdomen.
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Indications for use of a syringe driver in patients nearing the end of life include\:
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Requiring two or more doses of any one of the anticipatory medications in a 24 hour period
Being unable to take oral medications that need replacing (e.g. modi
Continuous infusion provides a constant level of medication to the patient, which helps to achieve better symptom control.
Only medications that a patient has required are put into a syringe driver. Therefore, regular reviews are important as they may
still require further ‘as required’ doses of medication on top of those in the syringe driver. These may be the same medications
they are already receiving or one of the other anticipatory medications.
Example
Mrs X has pancreatic cancer and is in the last days of life. She has developed noisy breathing and agitation in the last 24
hours. She has required 3 x 20mg doses of hyoscine butylbromide and 2 x 2.5mg doses of midazolam. A syringe driver
containing 60mg of hyoscine butylbromide and 5mg of midazolam over 24 hours is commenced.
You review Mrs X 24 hours after starting her syringe driver as above. Her family report that she has continued to have
some noisy breathing, requiring two further doses of 20mg hyoscine butylbromide. She has also had 1 x 5mg midazolam
for agitation and 1 x 5mg morphine sulphate for pain.
Therefore, you prescribe a new syringe driver containing 100mg hyoscine butylbromide, 10mg midazolam and 5mg
morphine sulphate.

Syringe driver prescribing

Separate drug charts are usually used for prescribing syringe drivers. Many drugs can be mixed together safely in a syringe
driver, but it is important to check compatibility. Further details can be sought from local guidelines, pharmacists or the local
palliative care team. When setting up a syringe driver, most drugs are diluted in water for injection.

Key points

Anticipatory medications are essential prescriptions for patients nearing the end of their life to ensure good symptom
control
Syringe drivers are commonly used to optimise symptom control by delivering a continuous subcutaneous infusion of
medications that are needed
It is important to thoroughly explain and discuss the use of anticipatory medications and syringe drivers with patients and
their relatives
Although medications play an important role, non-pharmacological methods are also important in managing symptoms

Reviewer

Dr Tammy Oxley
Palliative Care Registrar
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References

1. NHS Scotland. Scottish Palliative Care Guidelines, Anticipatory Prescribing. 2014, updated 2020. Available from\: [LINK]
2. Care of dying adults in the last days of life. December 2015. Available from\: [LINK]
3. NHS England – Yorkshire and the Humber End of Life Care Group. A guide to symptom management in palliative care. June
2019. Available from\: [LINK]
4. Moira Cookson, Sarah Mcdermott, Chris Toothill, Jason Ward – Leeds Community Healthcare NHS Trust. Symptom
Management Guidance in the Last Days of Life. December 2017. Available from\: [LINK]
5. NHS Scotland. Scottish Palliative Care Guidelines, Pain Assessment. 2014, updated 2021. Available from\: [LINK]
6. Marie Curie. Palliative Care Knowledge Zone, Pain. 2021. Available from\: [LINK]
7. Marie Curie. Palliative Care Knowledge Zone, Agitation. 2021. Available from\: [LINK]
8. Marie Curie. Palliative Care Knowledge Zone, Syringe Pumps. 2021. Available from\: [LINK]
Source\: geekymedics.com
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