Anticipatory ‘Just in case’ Prescribing Guideline for

Adults
Title: Anticipatory ‘Just in case’ Prescribing Guideline for Adults

Status: FINAL
Version No: 1.1
Date Approved by BOB APC: September 2022
Next Review: September 2025
Authors: Jane Bywater, Consultant in Palliative Medicine, Sue Ryder and BOB
ICS Palliative and End of life Clinical Lead. Emilia Moretto, Consultant in
Palliative Medicine and Clinical Lead Palliative Medicine, Sue Ryder.
Victoria Bradley, Clinical Lead for and Consultant in Palliative Medicine,
OUH. Mel Presland, Consultant Pharmacist- Palliative and End of Life
Care, OUH. Ed Capo-Bianco, GP, Urgent Care, Palliative and End of
Life Care, Cardiovascular Disease Clinical Lead for Oxfordshire Place in
ICB. Liz Monaghan, Palliative Care Matron, BHT. Helen Pegrum,
Consultant in Palliative Medicine, BHT. Noreen Casey, Macmillan
Advanced Palliative Care Pharmacist, Stoke Mandeville Hospital, BHT.
Change History: Final 1.1 November 2022 (formatting and minor correction)
Final 1.0 September 2022

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 Anticipatory ‘Just in case’ Prescribing Guideline for Adults
This guideline is intended for use by primary care clinicians.
Please seek specialist advice if you are unsure regarding the management/care of the patient at any point

There are some small variations with doses between this document and full local palliative care guidelines available in some ICB areas, but these doses have been clinically
agreed by local palliative care specialists. Please note full local guidelines can be found:
• Berkshire West: Berkshire Adult Palliative Care Guidelines Best Practice (Section 1+2)
Berkshire Adult Palliative Care Guidelines Best Practice (Section 3)
• Buckinghamshire: Palliative Care Symptom Control (bucksformulary.nhs.uk)
Care of the Dying Patient (bucksformulary.nhs.uk)

Anticipatory, or ‘Just in case’, prescribing forms a key part of pro-active end symptom management at the end of life (EoL). It ensures that, in last days/hours of life, there is
reduced delay in responding to symptoms. NICE ‘Care of dying adults in last days of life’ (NG31) offers guidance on this also.

Prescribing needs to be considered when:

• You think the patient is in the last few weeks of life
• Amber or Red on Palliative care Register (i.e. unstable or likely to change)
• Patient at home on syringe pump
• Patient for whom fast track Continuing Healthcare (CHC) funding has been agreed
• Unstable symptom issues such as
Poorly controlled symptoms with concern about absorption
Likelihood for vomiting
Conservatively managed bowel obstruction
History of seizures and potential need to switch to subcutaneous route if loses oral route
Medical conditions where medication may be needed by alternative routes when patient unable to swallow
Variable ability to swallow

All patients dying at home should have a supply of anticipatory subcutaneous medication but not all patients who are dying will require a syringe pump. A syringe pump
should not be prescribed in anticipation but should only be prescribed at the time it is required. Consider using a syringe pump to deliver medicines if more than 2 or 3
doses of any 'as required' (PRN) medicines have been given within 24 hours or if oral route is lost and the patient is on medication that it is appropriate to transition into
the subcutaneous route. A syringe pump takes at least 4 hours to establish a steady state drug level in plasma. If the patient is in pain, has nausea/vomiting or is agitated
give a when required subcutaneous injection of appropriate medication whilst waiting for the syringe pump to take effect

Seek specialist advice when symptoms persist, patient continues to require frequent PRN medications, if moderate-severe renal or hepatic impairment or if exceeding
typical maximum doses. Request advice if there is concern about drug effectiveness, &/or side-effects.

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Please ensure a Direction To Administer (DTA) is completed at the time of prescribing these can be completed in EMIS.
Please see Form: Direction to Administer - Generic Referral form (clinox.info) for further information in Oxfordshire.

For Specialist advice, telephone contacts:

Oxfordshire patients:
OUH Palliative Care Hub
9am to 5pm daily: 01865 857036
A senior doctor in Palliative Medicine is available via OUH switchboard for urgent out of hours advice 0300 304 7777
Sue Ryder Team Palliative Care Hub (South Oxfordshire) 8am – 8pm 7 days a week 0330 053 6092
OOH urgent advice contact Royal Berkshire Hospital switchboard for On Call Consultant

Berkshire West patients:

Community patients 9-5, Monday- Friday: West Berks 01635273720/ Reading 01189505276 / Wokingham 01189787843
Weekend Daytime and BH on call Clinical Nurse Specialist CNS 07899 915619
OOH urgent advice contact Royal Berkshire Hospital switchboard for On Call Consultant

Buckinghamshire patients:
Specialist Medical Advice is available 24/7 via Florence Nightingale Hospice 01296 332600

The Guaranteed Provision of Urgent Medication in the Community Scheme details a list of participating pharmacies and the list of palliative care drugs that these
pharmacies are guaranteed to stock. Please note that carers and healthcare professionals are not restricted to obtaining palliative care drugs only from the pharmacies
taking part in this scheme. Prescriptions for palliative care drugs can be fulfilled by any other community pharmacy. For full details please see The Guaranteed Provision of
Urgent Medication in the Community Scheme

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 PRESCRIBING GUIDANCE FOR DRUGS ON AN ‘AS REQUIRED’ BASIS
NAME OF DRUG & AS REQUIRED (PRN) FREQUENCY & MAXIMUM DOSE in ROUTE PRESCRIBING COMMENTS Suggested
INDICATION/SYMPTOMS DOSE MINIMUM PRN 24hrs before seeking number of
DOSE INTERVAL specialist advice ampoules
MORPHINE SULPHATE injection Morphine 2.5- 5 mg if Usual maximum is 6 SC Seek specialist advice if:
CD 10mg/ml † opioid naive doses of prn in 24hrs -high doses of opiate eg > 120mg
OR Oxycodone 1.25-2.5mg if morphine oral/24hrs
OXYCODONE injection opioid naive Prescribe a maximum dose -on transdermal patch (fentanyl or 5-10
(Clinical variation
CD 10mg/ml † buprenorphine
1-2 hourly PRN may require
1. Pain If already on regular oral -if renal and/or hepatic impairment adjustment of the
2. Breathlessness (1st line) morphine/oxycodone, PRN dose may quantity prescribed)
be higher. Divide total daily oral dose Use with caution in low eGFR - OXYCODONE
by 2 to calculate 24 hr SC equivalent. usually preferred when eGFR<30
Then divide by 6 to calculate SC PRN.
1. Anxiety 30mg/24h & then review and SC *1 hourly PRN under specialist guidance
2. Restlessness & seek specialist advice
agitation without 2.5-5mg
evidence of 5-10
MIDAZOLAM 2 hourly PRN* (Clinical variation
hallucinations
injection † may require
3. Breathlessness
CD 10mg/2mls adjustment of the
(2nd line) quantity prescribed)

Risk of seizure Can be repeated if seizures persist seek

10mg
Once specialist advice
HYOSCINE BUTYLBROMIDE 20mg 4-8 hourly PRN* 1. Respiratory secretions: SC *Seek specialist advice if not controlled. 5-10
(BUSCOPAN) injection †20mg/ml 60mg/24hrs & then review (Clinical variation
1. Respiratory secretions 2. Abdominal colic/secretions: Do not confuse with hyoscine may require
2. Abdominal colic/secretions 120mg/24h & then review hydrobromide adjustment of the
quantity prescribed)
HALOPERIDOL injection 5mg/ml † 0.5-1.5mg 4 hourly PRN if 0.5mg 3mg/24h & then review SC (1st line antiemetic)
1. Nausea & vomiting dose Do not prescribe in Parkinson’s 5-10
2. Hallucinations OR disease – seek specialist advice (Clinical variation
3. Agitation /delirium 1.5mg BD PRN may require
adjustment of the
Caution: Dose accumulation can occur due to
quantity prescribed)
OR long half life.

LEVOMEPROMAZINE injection 6.25-25mg dose range varies (2nd line antiemetic)

25mg/ml according to indication: 25mg/24h & then review. More sedating than haloperidol.
1. Nausea & vomiting Seek specialist advice if dose Lower end of dose range for nausea & 5-10
2. Agitation/delirium 1. Nausea & vomiting BD PRN (Clinical variation
above 25mg/24hrs if used for vomiting. Do not prescribe in Parkinson’s
3. Severe terminal agitation may require
6.25mg (lower range) nausea and vomiting and SC disease – seek specialist advice. adjustment of the
2. Agitation/delirium 4 hourly PRN above 50mg/24hrs if used for quantity prescribed)
6.25-12.5mg agitation/delirium. Caution: Dose accumulation can occur due to
3. Severe terminal agitation 4 hourly PRN long half life.
12.5-25mg (higher range)

† denotes the use of medications that are licensed but being used outside of their product licence (off label) but use is ‘generally accepted’ in palliative care
CD = Control Drug, SC = Subcutaneous, PRN = As Required, BD = twice a day
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PRESCRIBING GUIDANCE FOR DRUGS VIA A SYRINGE PUMP CONTINUOUS SUBCUTANEOUS INFUSIONS (CSCI)

DRUG VIA CSCI INDICATIONS FOR USE STARTING DOSE Typical COMMENTS DILUENT
RANGE/24HR MAXIMUM/24HR
MORPHINE Opioid responsive pain Determined by No true ceiling dose To convert total daily dose of oral morphine to 24h SC syringe Water
SULPHATE † Breathlessness previous opioid (response pump dose divide by 2. For
CD requirements dependent) Prescribe SC breakthrough dose of 1/6th of total 24h SC Injection
1st line opioid analgesic morphine dose in syringe pump. (WFI)
OXYCODONE † Opioid responsive pain Determined by No true ceiling dose To convert total daily dose of ORAL oxycodone to 24h SC WFI
CD Breathlessness previous opioid (response syringe pump dose divide by 2.
If morphine requirements dependent) Prescribe SC breakthrough dose of 1/6th of total 24h SC
not tolerated or renal oxycodone dose in syringe pump.
impairment (eGFR less than
30ml/min)
2nd line opioid analgesic
CYCLIZINE † Nausea & vomiting (N & V) 75mg/24h 150mg/24h Slows peristalsis in GI tract & acts directly on vomiting centre. WFI ONLY
Relatively safe antiemetic in Parkinson’s disease.
Useful for N & V due to raised
intracranial pressure Anticholinergic effects of cyclizine block prokinetic
or vestibular disturbance action of metoclopramide – do not prescribe concurrently
HALOPERIDOL † Nausea & vomiting 0.5-1.5mg/24h 5mg/24h Antipsychotic, but at lower doses useful for WFI
Hallucinations/delirium 1.5-5mg/24h metabolic/chemical causes of N & V. Do not prescribe in
Parkinson’s Disease -seek specialist advice.
METOCLOPRAMIDE † Nausea & vomiting 30mg/24h 30mg-60mg/24h Prokinetic antiemetic useful for N & V caused by gastric stasis. WFI
Avoid if complete bowel obstruction or colic. Do not prescribe
Please seek specialist advice re higher in Parkinson’s Disease -seek specialist advice.
doses/if symptoms are not controlled
as doses above this may be used.
LEVOMEPROMAZINE Nausea & vomiting 5mg/24h 25mg/24h Broad spectrum 2nd line antiemetic. More sedating than WFI or 0.9%
Agitation /sedation 12.5-25mg/24h haloperidol. Sedation & postural hypotension at higher doses. Sodium
Severe agitation 25-50mg/24h Please seek specialist advice re higher Higher doses sometimes required for severe terminal agitation Chloride as
doses/if symptoms are not controlled unresponsive to haloperidol/midazolam. Do not prescribe in reduce risk
as doses above this may be used. Parkinson’s disease – seek specialist advice. inflammation
MIDAZOLAM † Anxiety/Agitation/Restlessness 5-15mg/24h 10mg/24h Used to replace oral anti-epileptics at EoL. Seek advice in WFI
CD Breathlessness Seek advice if exceed 60mg/24h patients losing the oral route who are not thought to be dying.
In terminal agitation, always exclude urinary retention & pain.
Seizures 20-30mg/24h Please seek specialist advice re higher
doses/if symptoms are not controlled
as doses above this may be used.
HYOSCINE Respiratory tract secretions 40-60mg/24h 120mg/24h Give early to prevent build up of respiratory tract secretions. WFI
BUTYLBROMIDE † Colic pain Antispasmodic slows peristalsis & reduces secretions in GI
(BUSCOPAN) Gastrointestinal obstruction tract.

† denotes the use of medications that are licensed but being used outside of their product licence (off label) but use is ‘generally accepted’ in palliative care
CD = Control Drug, SC = Subcutaneous, PRN = As Required

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 Palliative Care Opioid Conversion Chart

NOTE: When using this chart, calculate the total daily dose of morphine.
Once you have converted from oral morphine, ensure opioid dose is prescribed in divided doses as appropriate.

SUBCUTANEOUS MORPHINE ORAL OXYCODONE mg/day

mg/day

x2 ÷2
÷2 x2
SUBCUTANEOUS TRANSDERMAL FENTANYL
OXYCODONE mg/day x4
PATCH micrograms/hour
÷3

÷4
x3

÷10 ÷2.4 TRANSDERMAL

ORAL ORAL
TRAMADOL/CODEINE BUPRENORPHINE PATCH
MORPHINE x2.4 micrograms/hour
mg/day
x10 mg/day

* The conversions given are comparable doses but there is wide patient intervariability relating to opioid conversion.

In renal impairment (GFR less than 40ml/min) In renal impairment (GFR less than 20ml/min)
Using the chart
Morphine and codeine can both accumulate. Consider Seek specialist advice from the palliative care team.
alternative if eGFR less than 30ml/min.
• The RED arrow OUTWARD shows how to
convert from morphine to the alternative drug
Alternative opioids of choice are oxycodone oral/scut
• The BLUE arrow INWARD shows
fentanyl and buprenorphine patches. If using other
how to get the equivalent dose of
analgesics, use low doses and increase the dose
oral morphine. See overleaf.
interval,and regularly monitor and review.

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 Palliative Care Opioid Conversion Chart

Opioid Drug Conversions- Example calculations from weak opioids to

General Guidelines oral morphine
• This chart is designed for guidance only. The conversions
given are comparable doses but there is wide patient
intervariability relating to opioid conversion. For individual
Dose of weak Calculation to Suggested
patients, response to previous opioids, clinical condition
opioid oral morphine prescribed total
and severity of pain must be taken into consideration.
24 hr daily dose
• The chart is intended to be used as a guide by working of oral morphine
through the oral daily dose equivalent of morphine (mg)
Codeine 60mg Codeine 240 ÷ 10 20
• Take care if switching from oral to parenteral opioids if QDS = 24mg/day
clinical concerns regarding oral absorption.

• For patients on higher doses of opioids Tramadol Tramadol 400 ÷ 40

(morphine>120mg/day), specialist palliative care 100mg 10
assessment andadvice should be sought. QDS = 40mg / day

• It is good practice to document your rationale for opioid

switching.

• When calculating doses always double check your

calculation, with someone else if possible. Example alternative opioid calculations from
total daily dose of 80mg oral morphine
• Round doses up or down to a sensible number
dependent upon the drug and formulations available.
Daily 24hr Calculation to Suggested
• Remember to prescribe breakthrough doses for PRN use dose of alternative prescribed dose of
(1/6 of total daily dose). morphine opioid alternative opioid
(mg)
• To convert to/from methadone – seek specialist advice 80 Fentanyl patch Fentanyl patch
from the palliative care team 80 ÷ 3 = 26.66 25microgram/hour
microgram/hour

80 Subcutaneous Subcutaneous
Please be aware that there are several different oxycodone oxycodone
buprenorphine patches available. 80 ÷ 4 = 20mg/ 20 mg per 24 hours
day
Some are changed weekly e.g. Butec and BuTrans, 80 Oral oxycodone Oral oxycodone S/R
others are changed twice weekly e.g. Transtec and 80 ÷ 2 = 40mg/ 20 mg BD
Bupeaze (96hrs) or Hapoctasin (72 hrs). day

80 Buprenorphine Buprenorphine patch

patch 35 microgram per
Please see the BNF or Summary of Product
80 ÷ 2.4 = 33.3 hour
Characteristics (available at www.medicines.org.uk) for
microgram/hour
fulldetails of all available products.

References

Berkshire Adult Palliative Care Guidelines Best Practice Document V3 2019

Sue Ryder Anticipatory ‘Just in case’ Prescribing Guidelines Dec 2021.
OUH Palliative Care Opioid Conversion Chart V1.1 Jan 2022

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Title of Guideline Anticipatory ‘Just in case’ Prescribing Guideline for
Adults
Guideline Number 900FMB
Version 1.1
Effective Date September 2022
Review Date September 2025
Approvals:
Give details of approval at appropriate BOB APC 2022
Governance meeting(s)
Medicines Check (Pharmacy) 17th November 2022
To be noted by Clinical Guidelines 20th December 2022
Group
Author/s Jane Bywater, Consultant in Palliative Medicine Sue
Ryder and BOB ICS Palliative and End of life Clinical
Lead
SDU(s)/Department(s) responsible for Pharmacy
updating the guideline
Date uploaded 17th May 2023
Buckinghamshire Healthcare NHS Trust

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