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Scottish Palliative Care Guidelines print pdf

Anticipatory Prescribing

Introduction

If a patient is in the last days of life at home or in a care home, it is usually helpful if medication for end-of-life symptom control is available so that these medicines can be given if required without unnecessary delay. Some areas have arranged 'just in case' boxes including the most important medicines which might be required to avert crises, and pre-printed administration charts requiring doctor’s signature. Community nurses supply box and syringes and sharps disposal.

The decision to prescribe medication for use in the future should always be based on a risk/benefit analysis. Reasons for not providing anticipatory medicines include risk of drug diversion or misuse.

A community medication administration chart is needed with the dose, route, frequency and indication(s) before nurses in the community can administer medicines. This is usually written by the general practitioner.

Read the Last days of life guideline

Management

Anticipatory medication

  • If a patient is currently receiving subcutaneous (SC) analgesics, anxiolytic/sedatives or anti-emetics, or antipsychotics, an additional anticipatory medication supply may not be needed. Check what medicines are already available in the patient’s home before prescribing new anticipatory medication.
  • Morphine and diamorphine SC are the opioids of choice. The dose given here is for a patient not receiving any regular opioid. If the patient is taking a regular opioid, a different breakthrough dose of opioid may be needed; usually equivalent to 1/10th to 1/6th of the 24-hour regular opioid dose.
  • Read the Choosing and changing opioids guideline.
  • If the patient has stage 4/5 chronic kidney disease/severe renal impairment (eGFR <30ml/min), use alfentanil SC, not morphine SC or diamorphine SC.
  • Read the Renal Disease in the last Days of Life guideline.

Medication

Anticipatory prescription

The prescription should include the five medications that might be required for end-of-life symptom control, plus diluent.

It is important that prescription wording for controlled drugs meets legal requirements to reduce delays in dispensing. Sample CD prescription.

Analgesic:

morphine sulfate injection (10mg/ml ampoules)
Dose: 2mg SC, hourly as needed for pain or breathlessness. Supply five (5) 1ml ampoules.

OR

diamorphine hydrochloride injection (powder for reconstitution)
Dose: 2mg SC, hourly as needed for pain or breathlessness
Supply five (5) 5mg ampoules plus water for injection (10 ampoules of 10ml).


Anxiolytic sedative:
midazolam injection (10mg in 2ml ampoules)
Dose: 2mg SC, hourly as needed for anxiety/distress/myoclonus. Supply ten (10) ampoules of 2ml.

Anti-secretory:
hyoscine butylbromide injection (Buscopan®) (20mg/ml ampoules)
Dose: 20mg SC, hourly as needed for respiratory secretions. Maximum of 120mg in 24 hours. Supply 10 ampoules.

Anti-emetic:
levomepromazine injection (25mg/ml ampoules)
Dose: 2.5 to 5mg SC, 8 to 12 hourly as needed for nausea. Supply 10 ampoules.

OR

haloperidol injection (5mg/ml ampoules)
Dose: 500 micrograms SC, 12 hourly as needed for nausea. Supply five ampoules.

Antipsychotic:

haloperidol injection (5mg/1ml ampoules)
Dose: 2mg SC once or twice daily as required for confusion/delirium. Supply five ampoules.

OR

levomepromazine injection (25mg/ml ampoules)
Dose: 12.5mg SC 2 hourly as required for agitation/confusion/delirium (maximum of 6 doses/24 hours). Supply 10 ampoules.

Note: Please note that high doses of levomepromazine and haloperidol are generally only used as antipsychotics to treat delirium/confusion and in much lower doses for nausea/vomiting.