Synopsis
Predict likely last-days symptoms, prescribe patient-specific rescue medicines with safe doses and routes, ensure timely access and competent administration and convert repeated need into a reviewed continuous plan without routine over-sedation.
- 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.
Key red flags
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.
Repeated rescue without benefit, severe adverse effect, seizure, haemorrhage, stridor or a new reversible emergency requires immediate clinical escalation.
Investigation priorities
Identify the exact distress, severity, pattern, swallow, preferred alertness and reversible contributors before selecting a rescue medicine.
Management branches
The person may deteriorate quickly or lose oral access and delayed community prescribing would cause avoidable distress.
- Assess likely symptoms, current medicines, prior response, organ function, risks, alertness goals and who can administer in the intended setting.
- Prescribe only indicated rescue medicines with explicit concentration, dose, route, interval and escalation and arrange lawful supply, storage and equipment.
- Explain readiness versus administration to patient and family, share the plan across services and state the number for urgent clinical review.
Symptoms recur around the clock, several effective rescue doses are needed or essential oral regular medicines can no longer be given.
- Reconfirm diagnosis and total the preceding 24-hour effective medicines, including patches, then use validated conversion and pharmacy or palliative review.
- Prescribe only compatible indicated medicines in an appropriate diluent and volume, select a healthy subcutaneous site and retain separate rescue doses.
- Review symptom control, sedation, site and rescue use at least daily and adjust from actual need rather than routinely escalating the whole mixture.