It is essential to prescribe medications ahead to cover the commonest symptoms in the last days of life.
These must also be recorded on a MAAR Chart (see downloads) so that nurses can administer them at home.
This table gives options for the 5 key symptoms - pain, breathlessness, nausea, agitation and secretions. Choose one medication for each symptom.
For Controlled Drugs (CD) (Morphine, Oxycodone and Midazolam) the total number of ampoules must be written in figures and words (e.g. Supply 10 (Ten) x 10 mg/1 ml ampoules).
See the right hand side of this page for local pharmacies that stock end of life medications.
Recommended Prescribing of Anticipatory Medication on FP10
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Medicine |
Prescription Instructions Include frequency of dose or maximum dose in 24 hours |
Notes
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Options for pain or breathlessness |
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1.Morphine sulfate injection (CD Schedule 2) |
2.5 mg to 5 mg subcutaneously (SC) PRN up to 2 hourly Consider 1.25 to 2.5 mg for frail elderly or if breathlessness is the key symptom in opioid naive patients Supply 10 (Ten) x 10 mg/1 ml ampoules |
Dose depends on previous opioid dose. e.g. If on 60 mg per day of oral Morphine or more, then SC dose would start at 5 mg not 2.5 mg |
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2. Oxycodone injection (CD Schedule 2)
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1.25 mg to 2.5 mg SC PRN up to 2 hourly Supply 10 (Ten) x 10 mg/1 ml ampoules |
Dose depends on previous opioid dose. Preferred opioid if eGFR<30 ml/min |
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Options for nausea and vomiting |
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1.Haloperidol injection |
0.5 mg to 1.5 mg SC PRN Max dose 5 mg in 24 hours. Supply 5 x 5 mg/1 ml ampoules |
Need higher doses if using Haloperidol for agitation |
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2. Cyclizine injection
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25 mg to 50 mg SC PRN Max dose 100 mg in 24 hours. Supply 10 x 50 mg/1 ml ampoules |
Recent guidelines suggest limiting 24 hour dose to 100 mg, rather than 150 mg |
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3. Levomepromazine |
5 mg to 12.5 mg SC PRN up to 3 x daily. Can be sedative in doses greater than 12.5 mg in 24 hours. Supply 5 x 25 mg/1 ml ampoules |
Useful if agitation is anticipated alongside nausea (see below) |
| Options for respiratory secretions |
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| 1.Glycopyrronium injection |
200 to 400 micrograms SC PRN Max dose 1200 micrograms in 24 hours. Supply 10 x 200 micrograms/1 ml ampoules |
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| 2. Hyoscine butylbromide (Buscopan) |
20 mg SC PRN Max dose 120 mg in 24 hours Supply 10 x 20 mg/1 ml ampoules |
Also useful if abdominal colic anticipated e.g. in bowel obstruction |
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Options for agitation and restlessness |
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1.Midazolam Injection (CD Schedule 3) |
2.5 to 5 mg SC PRN for up to 2 hourly Supply 10 (Ten) x 10 mg/2 ml ampoules |
If severe agitation consider Levomepromazine |
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2. Lorazepam tablets
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0.5 to 1 mg to be given sublingually up to 2 hourly PRN for breathlessness/ anxiety/ agitation Max dose 3 mg/24 hours - this dose will be very sedative. Supply 14 x Lorazepam (e.g. Teva, Genus) 1 mg tablets |
If patient conscious prescribe sublingually - recognised unlicensed indication |
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3. Levomepromazine |
12.5 mg SC PRN up to 3 x daily. Can be sedative in doses greater than 12.5 mg in 24 hours. Supply 5 x 25 mg/1 ml ampoules |
For agitation, doses are 12.5 mg to 25 mg SC PRN up to 4 x daily Consult with Palliative care team |
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Crisis prescribing for haemoptysis, haematemesis and respiratory obstruction |
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1.Midazolam Injection (CD Schedule 3)
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5 mg to 10 mg IM PRN Supply 10 (Ten) x 10 mg/2 ml ampoules |
IM is preferable to SC in this situation and usually aiming for calm/unconscious |
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1.Morphine sulfate injection (CD Schedule 2)
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5 mg to 10 mg IM PRN Supply 10 (Ten) x 10 mg/1 ml ampoules |
IM is preferable to SC in this situation and usually aiming for calm/unconscious |
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Diluent for injections |
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Water for Injection |
Use as diluent Supply 10 x 10 ml ampoules |
In some areas Sodium chloride 0.9% is preferred rather than water for injection (but not for Cyclizine) |
Top tip: these doses may need revising as symptoms worsen or if background doses increase or if there is renal or liver failure
MAAR Chart - is a Medication Authorisation and Administration Record. It allows administration of medication by nurses and needs to be completed by a doctor or nurse prescriber to support the administration of the above injections or an infusion via a syringe pump. See downloads on the right for a PDF MAAR Chart.