Anticipatory Prescribing: Information for clinicians

It is essential to anticipate symptoms in advance and prescribe wisely to keep people safely at home in their final days.

Prescribing a small number of ampoules to cover the commonest symptoms is recommended.

Recommended Prescribing of Anticipatory Medication on FP10

       Medicine

Prescription Instructions

Include Maximum Dose 

Prescribe medicines needed to manage symptoms and adjust dose and frequency as situation changes.

   Quantity

Adjust quantity depending on patient need 

Morphine Sulfate Injection

(CD Schedule 2)

2.5mg to 5mg (0.25ml to 0.5ml) to be given  subcutaneously when required for pain or breathlessness up to hourly. Consider 1.25mg to 2.5mg (0.125ml to 0.25ml) for frail elderly or if breathlessness is key concern in opioid naive patients.

Dose depends on previous opioid dose.

Supply 10 (Ten) x 10mg/1ml ampoules

Oxycodone

(CD Schedule 2)

(eGFR<30ml/min)

1.25mg to 2.5mg(0.125ml to 0.25ml) to be given  subcutaneously when required for pain or breathlessness up to 2 hourly 

Dose depends on previous opioid dose.

Supply 10 (Ten) x 10mg/ml ampoules 

Haloperidol Injection

0.5mg to 1.5mg (0.1ml to 0.3ml) to be given subcutaneously i when required for nausea 

Max dose 5mg in 24 hours.

Supply 5 x 5mg/1ml ampoules

Cyclizine

1st line in Hillingdon

25mg to 50mg (0.5ml to 1ml) to be given subcutaneously when required for nausea 

Max dose 100mg in 24 hours.

Supply 10 x 50mg/ml ampoules 

Midazolam Injection

(CD Schedule 3)

2.5mg to 5mg (0.5ml to 1ml) to be given subcutaneously  when required for agitation/restlessness up to 2 hrly

Supply 10 (Ten) x 10mg/2ml ampoules

Glycopyrronium Bromide Injection

200 micrograms to 400 micrograms (1ml to 2ml) to be given subcutaneously when required for respiratory secretions.

Max dose 1200mcg in 24 hours.

Supply 5 x 200mcg/1ml ampoules

Water for Injection

Use as diluent

Supply 10 x 10ml ampoules

Sodium Chloride 0.9%

Tri-borough

Use as diluent (but not for cyclizine)

Supply 10 x 10ml ampoules

Levomepromazine

2nd/3rd line

6.25mg to 12.5mg (0.25ml to 0.5ml) to be given subcutaneously when required for nausea and vomiting up to 3 x daily.

Sedative in doses greater than 12.5mg in 24 hrs.

Supply 5 x 25mg/ml ampoules

Lorazepam tablets

(if patient conscious) Prescribe PO to be used sublingually - recognised unlicensed indication

0.5mg to 1mg to be given sublingually up to 2 hrly when required for breathlessness/ anxiety/ agitation 

Max dose 4mg/24 hours - this dose will be very sedative.

Supply 15 x 1mg tablets (Genus brand)

Top tip: these doses may need revising as symptoms worsen or if background doses increase

MAAR Chart - is a Medication Authorisation and Administration Record. It allows safe administration of medication and needs to be completed by a doctor or nurse prescriber to support the administration of anticipatory injections or an infusion via a syringe pump. See downloads on the right for a paper or writeable PDF MAAR Chart.

The MAAR chart is also integrated into EMIS under the EOL template for GPs

    • Provide full name and GMC number on pages 1-3 of chart.
    • Type initials in the prescriber 'sign and print' area for EACH medication prescribed.
    • The completed chart can be emailed from clinicians nhs.net email address to another nhs.net email 

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North West London ICS

Published 9th July 2022

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