Educational draft · awaiting clinical reviewUse Rapid for revision, not patient-care decisions. Check current national and local guidance and the BNF or BNFC before acting.
2 min synopsisUK scopeSources checked 27 Aug 2026Clinical review pending
!
Symptoms not responding to anticipatory rescue
Severe pain, dyspnoea, agitation or seizure that persists after correctly administered rescue may reflect wrong diagnosis, inadequate delivery, rapid deterioration or an emergency requiring a different pathway. Repeated unreviewed dosing can cause avoidable toxicity.
Action: Stay with the person, use ABCDE assessment proportionately, verify medicine, dose, route, site and time, and check pain source, retention, glucose, seizure and opioid toxicity. Call the named palliative or emergency service, give further treatment only under the escalation plan and arrange continuous or alternative therapy after senior review.
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.
Key red flags
Slow breathing, pinpoint pupils, myoclonus or profound new sedation after opioid rescue suggests toxicity or metabolite accumulation.
Uncontrolled or unexpected symptoms
Repeated rescue without benefit, severe adverse effect, seizure, haemorrhage, stridor or a new reversible emergency requires immediate clinical escalation.
Investigation priorities
01
First-line symptom and route assessmentFirst stepFirst linePreferred
Identify the exact distress, severity, pattern, swallow, preferred alertness and reversible contributors before selecting a rescue medicine.
Management branches
Advance prescriptionPredict symptoms and individualise the set
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.
Continuous infusionConvert repeated need into stable control
Symptoms recur around the clock, several effective rescue doses are needed or essential oral regular medicines can no longer be given.
Key medicines
Subcutaneous morphine rescue when opioid naiveA 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.
Subcutaneous midazolam rescueFor 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.
National guidance is shown before implementation-dependent detail. Typical adult dose examples remain subject to patient factors, contraindications and the live BNF or specialist protocol. Source check completed 27 Aug 2026; clinical approval remains outstanding.
NICE NG31 care of dying adultsIndividual anticipatory prescribing, lowest effective doses, non-drug care and treatment review.