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 10mg/1ml 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) |
2.5mg to 5mg subcutaneously PRN up to 2 hourly Consider 1.25mg to 2.5mg for frail elderly or if breathlessness is the key symptom in opioid naive patients Supply 10 (Ten) x 10mg/1ml ampoules |
Dose depends on previous opioid dose. e.g. If on 60mg per day of oral Morphine or more, then subcut dose would start at 5mg not 2.5mg |
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2. Oxycodone injection (CD Schedule 2)
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1.25mg to 2.5mg subcutaneously PRN up to 2 hourly Supply 10 (Ten) x 10mg/ml ampoules |
Dose depends on previous opioid dose. Preferred opioid if eGFR<30ml/min) |
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Options for nausea and vomiting |
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1.Haloperidol injection |
0.5mg to 1.5mg subcutaneously PRN Max dose 5mg in 24 hours. Supply 5 x 5mg/1ml ampoules |
Need higher doses if using Haloperidol for agitation |
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2. Cyclizine injection
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25mg to 50mg subcutaneously PRN Max dose 100mg in 24 hours. Supply 10 x 50mg/ml ampoules |
Recent guidelines suggest limiting 24 hour dose to 100mg, rather than 150mg |
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3. Levomepromazine |
5mg to 12.5mg subcutaneously PRN up to 3 x daily. Can be sedative in doses greater than 12.5mg in 24 hrs. Supply 5 x 25mg/ml ampoules |
Useful if agitation is anticipated alongside nausea For agitation, doses are 12.5mg - 25mg subcut PRN up to 4 x daily Consult with Palliative care team |
| Options for respiratory secretions |
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| 1.Glycopyrronium injection |
200 micrograms to 400 micrograms subcutaneously PRN Max dose 1200mcg in 24 hours. Supply 10 x 200mcg/1ml ampoules |
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| 2. Hyoscine butylbromide (Buscopan) |
20mg subcutaneously PRN Max dose 120mg in 24 hours Supply 10 x 20mg/1ml 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) |
2.5mg to 5mg subcutaneously PRN for up to 2 hourly Supply 10 (Ten) x 10mg/2ml ampoules |
If severe agitation consider Levomepromazine |
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2. Lorazepam tablets
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0.5mg to 1mg to be given sublingually up to 2 hrly PRN for breathlessness/ anxiety/ agitation Max dose 3mg/24 hours - this dose will be very sedative. Supply 14 x 1mg tablets (Genus or TEVA brand) |
If patient conscious prescribe sublingually - recognised unlicensed indication |
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Diluent for injections |
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Water for Injection |
Use as diluent Supply 10 x 10ml 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
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.