Anticipatory prescribing

01Purpose and principlesWhat the treatment does and how it fits into care.

Anticipatory prescribing separates readiness from administration. A set of medicines may be supplied because symptoms are plausible, but a trained clinician or authorised carer assesses the actual symptom before each dose. One universal pack is unsafe: the opioid-tolerant patient, a person with kidney failure and someone with Parkinson disease need different drug and dose choices.

Review current pain, breathing, anxiety, delirium, nausea, secretions, seizures and swallowing. Record all opioid, benzodiazepine, antipsychotic, anticonvulsant and transdermal exposure over the previous 24 hours. Check kidney and liver function when available and clinically relevant, allergy, prior adverse effects, Parkinsonism, prolonged QT, urinary retention and glaucoma. Ask the person whether alertness or deeper symptom relief is their priority.

Pain and breathlessness often use the same opioid, but the dose comes from current exposure and organ function. An opioid-naive adult may receive a small subcutaneous morphine rescue under local guidance; a person already taking a strong opioid usually receives a calculated fraction of the effective 24-hour amount. Morphine metabolites accumulate in severe kidney failure, so seek specialist advice for an alternative such as alfentanil or carefully selected oxycodone.

Anxiety and terminal agitation are different. Midazolam can relieve acute panic, distress and seizure and may contribute to delirium management, but retention, faecal impaction, pain, medicine toxicity and family or environmental distress should be addressed. A low rescue dose is reviewed before repetition. Persistent severe delirium may require an antipsychotic or combined specialist plan rather than escalating benzodiazepine alone.

Select antiemetic by mechanism and prior response. Haloperidol may suit chemical nausea but is problematic in Parkinson disease, Lewy-body dementia and some QT-risk contexts. Levomepromazine covers mixed refractory pathways but is sedating and hypotensive. Metoclopramide treats gastric stasis but is unsafe in complete obstruction. Cyclizine may worsen anticholinergic delirium, retention and dry mouth.

Respiratory secretion treatment begins with explanation, lateral or slight repositioning if comfortable and avoidance of burdensome deep suction. Hyoscine butylbromide, glycopyrronium or another locally approved antimuscarinic can reduce new secretion production but cannot remove fluid already pooled. Earlier administration may work better; review dry mouth, retention and agitation and avoid promises that the sound will disappear.

A syringe driver is considered when the oral route has failed and repeated symptoms or stable essential medicines require continuous delivery. Calculate the preceding 24-hour effective use, convert opioids with a validated source, keep rescue available and check compatibility, diluent, volume, site and device. Do not put every anticipatory medicine into a pump pre-emptively; each component needs an indication.

Operational safety is as important as pharmacology. Confirm who can prescribe, collect, store and administer controlled drugs; whether district nurses can attend; and what happens overnight. Give family a written contact route and explain that they are not expected to diagnose symptoms or give injections unless an authorised programme, training and willing agreement exist. Reconcile supplies after admission, transfer and death.

Key points

Anticipatory medicines are prescribed before likely symptoms so relief is available without crisis delay; they are not administered simply because a person may be dying.
First-line assessment predicts pain, breathlessness, agitation, nausea, respiratory secretions and seizure from current symptoms, disease, existing medicines, kidney and liver function and care setting.
Every prescription must state indication, medicine, concentration, dose, route, minimum interval, maximum or escalation rule and what monitoring follows administration.
Use the lowest effective patient-specific rescue dose. Existing opioid or benzodiazepine exposure changes the starting dose substantially; renal failure changes drug choice.
Subcutaneous bolus is usually the practical non-oral rescue route in the last days. A continuous subcutaneous infusion maintains control but does not provide immediate rescue.
Continue a transdermal opioid patch unless a deliberate specialist change is made; calculate rescue and any infusion around the patch rather than accidentally duplicating or omitting baseline opioid.
Repeated effective rescue doses over 24 hours can inform a syringe-driver dose, but first confirm that the symptom and medicine are correct and exclude reversible distress such as retention.
For noisy respiratory secretions, explain that the sound often distresses relatives more than the unconscious patient and combine repositioning and mouth care with selective antimuscarinic treatment.
Check controlled-drug supply, prescription validity, expiry, storage, administration authority, needles and pump access across nights, weekends and transfers.
The gold-standard anticipatory plan includes an after-dose review and a named escalation route when symptoms persist, adverse effects occur or more than expected rescue is required.

02Indications, selection and cautionsWho may benefit, who needs urgent treatment and important alternatives.

Oral route failure

Dysphagia, repeated coughing, vomiting, reduced consciousness or inability to coordinate tablets signals need for a planned non-oral route.

Incident symptom need

Intermittent pain, dyspnoea, panic, nausea or agitation may respond to individual subcutaneous rescue without a continuous infusion.

Persistent symptom burden

Repeated effective rescue, around-the-clock recurrence or essential regular medicine indicates possible need for continuous delivery after reassessment.

Wrong-target distress

Retention, impaction, hypoglycaemia, pressure pain or opioid toxicity can appear as agitation and will not improve safely through indiscriminate sedation.

Family-distressing secretions

Gurgling upper-airway noise in an unconscious person may not indicate suffering, but requires explanation, mouth care and selective treatment.

Uncontrolled or unexpected symptomsRed flag

Repeated rescue without benefit, severe adverse effect, seizure, haemorrhage, stridor or a new reversible emergency requires immediate clinical escalation.

Red flags requiring action

Slow breathing, pinpoint pupils, myoclonus or profound new sedation after opioid rescue suggests toxicity or metabolite accumulation.
Repeated agitation dosing without checking retention, constipation, pain, hypoglycaemia and medication effects risks masking reversible distress.
Parkinson disease or Lewy-body dementia makes haloperidol and several dopamine antagonists potentially dangerous.
Complete bowel obstruction makes routine metoclopramide unsafe because prokinetic pressure can worsen colic or perforation risk.
Severe renal impairment changes opioid and sedative clearance and requires specialist choice rather than simple dose repetition.
A syringe driver does not deliver a rapid rescue bolus and must not be the only response to an acute crisis.
A missing, expired or inaccessible controlled drug prescription is a systems emergency before symptoms arise.

03Assessment before treatmentTests and checks that guide safe selection.

Investigation order

Read from the initial assessment onwards. Tests may run in parallel in urgent care; first-line, preferred, confirmatory, definitive and gold-standard labels appear only when the chapter explicitly states them.

01
First-line symptom and route assessmentFirst stepFirst linePreferred
Why
Identify the exact distress, severity, pattern, swallow, preferred alertness and reversible contributors before selecting a rescue medicine.
Interpretation and limitations
The symptom mechanism and route, not a generic last-days label, determine appropriate treatment.
02
Previous 24-hour medicine calculation
Why
Total regular and rescue opioid, benzodiazepine, antiemetic and other relevant exposure including transdermal patches.
Interpretation and limitations
This is the reference baseline for rescue and infusion dosing; omitted patches or rescue doses cause dangerous conversion error.
03
Renal, hepatic and interaction review
Why
Use recent organ function, clinical decline and interacting sedatives or QT medicines when information can alter drug or dose.
Interpretation and limitations
Severe renal failure often requires a different opioid; a normal historic result may no longer represent dying physiology.
04
Reversible-distress bedside screen
Why
Check bladder, bowel, pressure areas, glucose, temperature, medication timing and environmental or communication distress.
Interpretation and limitations
A correctable trigger should be treated directly while rescue relieves immediate suffering.
05
Supply and administration audit
Why
Confirm signed prescription, concentration, route, interval, maximum, stock, expiry, storage, equipment and an authorised willing administrator.
Interpretation and limitations
A clinically correct prescription cannot help if medicine or trained response is unavailable at the care site.
06
Post-dose response assessment
Why
Review symptom relief, alertness, respiratory rate, adverse effects and ongoing cause within the medicine-specific interval.
Interpretation and limitations
Response validates the choice and guides repeat or infusion; failure triggers reassessment rather than automatic escalation.

04Treatment approachPreparation, options, escalation and aftercare.

01Advance prescriptionPredict symptoms and individualise the setFirst stepThe person may deteriorate quickly or lose oral access and delayed community prescribing would cause avoidable distress.

1Assess likely symptoms, current medicines, prior response, organ function, risks, alertness goals and who can administer in the intended setting.
2EscalationPrescribe only indicated rescue medicines with explicit concentration, dose, route, interval and escalation and arrange lawful supply, storage and equipment.
3Explain readiness versus administration to patient and family, share the plan across services and state the number for urgent clinical review.

02Rescue administrationAssess, dose and review each symptomPain, breathlessness, agitation, nausea, secretion distress or seizure occurs and oral treatment is unreliable.

1Identify the symptom and immediate reversible contributors, check the last dose and current patch or infusion and confirm the prescription and subcutaneous site.
2Give the lowest effective authorised rescue dose and add non-drug measures such as position, airflow, calm presence, mouth care or bladder relief.
3EscalationReassess within the specified interval for benefit and toxicity and document outcome, escalating when the dose fails or repeated treatment is needed.

03Continuous infusionConvert repeated need into stable controlSymptoms recur around the clock, several effective rescue doses are needed or essential oral regular medicines can no longer be given.

1Reconfirm diagnosis and total the preceding 24-hour effective medicines, including patches, then use validated conversion and pharmacy or palliative review.
2Prescribe only compatible indicated medicines in an appropriate diluent and volume, select a healthy subcutaneous site and retain separate rescue doses.
3EscalationReview symptom control, sedation, site and rescue use at least daily and adjust from actual need rather than routinely escalating the whole mixture.

04Special circumstanceSeek early expertise for high-risk prescribingSevere renal or hepatic failure, Parkinsonism, complex opioid tolerance, uncontrolled delirium, seizure or medicine incompatibility is present.

1Contact specialist palliative care and pharmacy before routine drug selection or conversion and identify the symptom outcome and urgency.
2Use an organ-appropriate opioid, antiemetic or sedative and a separate emergency seizure or haemorrhage plan where indicated.
3Communicate non-standard doses and administration clearly to every team and review sooner for accumulation, paradoxical agitation or respiratory depression.

05Regimens, contraindications and interactionsTreatment details and the circumstances that modify them.

Relieves pain and can reduce distressing breathlessness when non-drug measures are insufficient and morphine is appropriate.

Subcutaneous morphine rescue when opioid naive

A common local last-days starting dose is morphine 2 mg subcutaneously as required no more often than hourly, with lower or alternative treatment in frailty or renal impairment and review after each dose.

Avoid routine use in severe renal failure, check prior opioid exposure and monitor alertness, respiratory rate, myoclonus, nausea and constipation; repeated need requires review.

Provides rapid relief of panic or severe distress and is also used in dedicated seizure protocols.

Subcutaneous midazolam rescue

For acute anxiety or agitation in a benzodiazepine-naive frail adult, a common local starting dose is 2 mg subcutaneously as required no more often than hourly, adjusted for prior exposure and specialist plan.

Exclude retention, pain and toxicity where possible; monitor paradoxical agitation, sedation and respiratory depression, especially with opioids or hepatic impairment.

Treats dopamine-mediated nausea from medicines or metabolic illness and may help selected delirium when non-drug care is insufficient.

Haloperidol for chemical nausea

A commonly used last-days rescue is haloperidol 0.5 mg subcutaneously once or twice daily as required, with continuous dosing considered only after response and local formulary review.

Avoid in Parkinson disease and Lewy-body dementia; review QT risk, rigidity, akathisia and extrapyramidal effects and do not use it as automatic sedation.

Reduces production of new upper-airway secretions when repositioning, mouth care and explanation are insufficient.

Hyoscine butylbromide for respiratory secretions

A common rescue is 20 mg subcutaneously as required up to hourly under the local last-days protocol; repeated effective doses may lead to a reviewed 24-hour continuous regimen.

It cannot remove existing pooled fluid and may cause dry mouth, urinary retention and anticholinergic effects; avoid burdensome deep suction and review whether the patient is distressed.

Broad receptor activity can relieve nausea of mixed or uncertain mechanism after a simpler matched antiemetic has failed.

Levomepromazine for mixed refractory nausea

A specialist rescue may begin with levomepromazine 2.5 to 5 mg subcutaneously once or twice daily as required, with any continuous dose based on response and local formulary limits.

Sedation, postural hypotension, anticholinergic effects and QT prolongation occur; use extra caution in frailty, Parkinsonism and concurrent sedatives.

06Complications, monitoring and follow-upAdverse effects, response and longer-term review.

After every rescue dose record indication, time, effect, alertness, respiratory rate and adverse effects before deciding on repetition.
Track total rescue use over each 24 hours, including doses before care or movement, and reconcile it with patches and infusions.
Inspect subcutaneous sites for redness, leakage, swelling, bleeding or poor absorption and rotate according to local policy.
Review syringe-driver contents, dose, compatibility, diluent, volume, remaining infusion and device function at every handover.
Monitor for renal accumulation through increasing sedation, hallucination, myoclonus or reduced respiratory rate and change medicine early.
Ask family whether breathing noise or symptom change has been explained and whether the contact and medicine process remains clear.
Check stock, expiry and controlled-drug record after every administration, transfer, prescription change and death.

07Special situationsVariants, exceptions and circumstances that change the usual approach.

Prescription is not indication

Supplying a medicine makes it available; a current symptom assessment still determines whether it should be administered.

A pump is not rescue

Continuous infusion establishes background delivery slowly, so separate bolus medicine remains necessary for acute distress.

Patches remain in the equation

Transdermal opioid continues contributing after oral intake fails and must be counted in rescue and conversion decisions.

Noise is not always suffering

Respiratory secretions may be alarming to family while an unconscious patient shows no distress, making explanation part of treatment.

Renal decline changes familiar doses

A previously safe morphine regimen can become toxic rapidly as filtration falls near death.

Availability is clinical safety

A perfect electronic prescription cannot relieve a midnight symptom when medicine, equipment or an authorised administrator is absent.

08Common pitfallsFrequent interpretation and management errors.

01
Administering every anticipatory medicine routinely because the person is dying.
02
Using identical drug and dose sets for opioid-naive, opioid-tolerant and renally impaired patients.
03
Forgetting transdermal opioid when calculating rescue or infusion treatment.
04
Escalating sedation before checking bladder, bowel, pain, glucose and medicine toxicity.
05
Using metoclopramide in complete obstruction or haloperidol in Parkinson disease.
06
Expecting a syringe driver to relieve an immediate crisis without a rescue dose.
07
Combining medicines in an infusion without compatibility and concentration review.
08
Repeating ineffective rescue without reassessing diagnosis, route and site.
09
Leaving controlled drugs inaccessible or expired over a weekend or transfer.
10
Expecting family to administer injections without authority, training and free agreement.