Guidance for Anticipatory Prescribing at the End of Life
Guidance for Anticipatory Prescribing at the End of Life
Final Version: Approved by NHS DGS CCG: February / 2016
This document provides guidance for...
Guidance for Anticipatory Prescribing at the End of Life
Final Version: Approved by NHS DGS CCG: February / 2016
This document provides guidance for non-specialist prescribers to support adult patients at the end of their life.
Guidance for Anticipator Prescribing at the End of Life Approved by DG&S CCG Clinical Cabinet Date of Approval: February 2016 Date of Review: February 2018
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Version Control
Version
Date
Comments
Version 1
July 2013
New document
Version 2
Version 3
Contributor
Transferred to new template.
Michelle Dutton
Additional guidance for oxycodone
Dr Andrew TysoeCalnon and DGS Medicines Optimisation Group
December 2015
February 2016
Amendments re: advice on oxycodone, opioid use in renal failure and EOL sc fluids
DGS CCG Clinical Cabinet
The following contributed to the development of these guidelines:
Dr. Andrew Tysoe-Calnon
Lead Consultant @ Ellenor hospice
Guidance for Anticipator Prescribing at the End of Life Approved by DG&S CCG Clinical Cabinet Date of Approval: February 2016 Date of Review: February 2018
Ellenor Hospice
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Anticipatory prescribing forms a key part of good pro-active end of life care and should be initiated as the patient enters the last few weeks of life. Issuing prescriptions for supportive medications in advance of anticipated need allows for prompt symptom relief whenever the patient develops distressing symptoms.
INTRODUCTION
It is essential to have an individualised approach to anticipatory prescribing. Patients approaching the end of their lives who express a desire to die at home require supportive care at home. This is particularly necessary when access to the patient’s own GP and regular pharmacy may not be possible. SCOPE OF GUIDELINES
THE All adult patients aged 18 years or over who are likely to need supportive medications at the end of their life. This guidance should be used in conjunction with NICE guidelines [NG31] : Care of dying adults in the last days of life
RECOMMENDATIONS
This document is recommended for use by all non-specialist prescribers within primary care. An anticipatory prescription should never be urgent. Good forward planning should allow time for the prescription to be written and collected in advance of any need for symptom control.
Guidance for Anticipator Prescribing at the End of Life Approved by DG&S CCG Clinical Cabinet Date of Approval: February 2016 Date of Review: February 2018
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PRESCRIBING INFORMATION Anticipatory prescribing forms a key part of good pro-active End of Life Care and should be initiated as the patient enters the last few weeks of life.
Ensure that in the last days or hours of life there is no delay in responding to symptoms Administer medication if and when needed, but no more than is required to relieve symptoms Review all medication including doses and frequency Commence a syringe pump if several PRNs required in 24 hours. Not all dying patients require a continuous subcutaneous infusion Contact the Specialist Palliative Care Team if symptoms persist If opioid naive, Morphine Sulphate 5-30mg sc over 24 hours in syringe pump with 2.5 – 5mg sc prn
Pain
If already on an analgesic patch, continue patch and add in sc morphine sulphate as required If already on oral morphine, divide 24 hr oral dose by 2 to calculate 24 hr syringe pump dose. If on other oral opioids, use conversion chart to calculate dose In renal failure, seek specialist advice
Haloperidol 3-5mg sc over 24 hr with 1.5mg sc prn Nausea / vomiting
Brain tumour/mets :Cyclizine 150mg sc over 24hr with 50mg sc prn Poor gut motility, Metoclopramide 30-60mg sc over 24hr
Agitation / Restlessness
Midazolam 10-40mg sc over 24 hr with 2.5-5mg sc prn
Respiratory Secretions
Glycopyrronium 0.6 -1.2mg sc over 24 hr with 0.2-0.4mg sc prn. Maximum 2.4mg in 24hr.
Dyspnoea
If opioid naive, Morphine sulphate 5-30mg sc over 24 hours with 2.5 - 5mg sc prn. Concurrent Midazolam recommended.
Guidance for Anticipator Prescribing at the End of Life Approved by DG&S CCG Clinical Cabinet Date of Approval: February 2016 Date of Review: February 2018
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Seizures
Midazolam 30-90mg over 24hr with 10-20mg sc prn. Start if patient either fitting or unable to take oral anti-epileptic drugs.
Intestinal Obstruction
Hyoscine butylbromide (Buscopan) 60-240mg sc over 24 hours with 20mg sc stat
Prescribing advice: Suggestions for the initial prescription for injectables:
Morphine sulphate 10mg/2ml x 10 amps (30mg/ml if on larger doses)
Haloperidol 5mg/ml x 10 amps
Midazolam 10mg/2ml x 10 amps
Glycopyrronium 600mcg/3ml x 10 amps
Remember to prescribe water for injection 10mls x 10amps
Other injectables:
Hyoscine butylbromide (Buscopan) 20mg/ml for bowel obstruction
Hyoscine hydrobromide (600mcg/ml) – alternative to Glycopyrronium
Morphine is recommended opioid for pain relief. If patient already on a different opioid (e.g. oxycodone) or you are considering using oxycodone in a syringe driver for a patient taking oral oxycodone, please contact the specialist palliative care team for advice on doses and conversions.
Renal failure :For patients with renal failure, seek advice from specialist palliative team SC Fluids :When faced with decisions about subcutaneous fluids administration at the end of life, please refer to specialist palliative care consultant Ellenor Hospice 0900-1700: Tel 01474 320 007 Ellenor Hospice OOH Tel: 01474 535 788
Guidance for Anticipator Prescribing at the End of Life Approved by DG&S CCG Clinical Cabinet Date of Approval: February 2016 Date of Review: February 2018
