👩‍⚕️ Assess symptoms regularly and titrate medicines to effect using the lowest effective dose.
💉 If the oral route is not possible or not tolerated, consider an alternative route; subcutaneous administration is commonly used, and NICE advises avoiding intramuscular injections.
🩺 Choose the most effective route based on the person’s condition, ability to swallow safely, and preferences.
📈 Reassess symptoms at least daily, and sooner if there is a change in condition or response.
🚰 If more than 2 or 3 PRN doses of any anticipatory medicine are needed within 24 hours, consider a syringe pump for continuous symptom control.
🤝 Care should be individualised, with communication and shared decision-making involving the patient and those important to them where appropriate.
☎️ Seek specialist palliative care advice promptly if symptoms do not improve or if treatment causes troublesome adverse effects such as unwanted sedation.

📊 Anticipatory Prescribing: Symptom Areas

💢 Pain: assess severity and reversible causes; manage promptly and match treatment to the likely cause and severity.
😮‍💨 Breathlessness: assess for reversible causes; consider an opioid, a benzodiazepine, or a combination. Do not routinely start oxygen unless there is known or suspected symptomatic hypoxaemia.
🤢 Nausea / vomiting: choose treatment according to the likely cause, side effects, and drug compatibility.
😵 Anxiety / delirium / agitation: look for contributing causes such as pain, urinary retention, constipation, or other unmet needs before escalating sedation.
💧 Noisy respiratory secretions: assess the likely cause, explain that the noise is often more distressing to others than to the dying person, and treat if appropriate.
⚡ Seizures: continue regular antiepileptic treatment where possible and use specialist/local palliative guidance for rescue and infusion regimens.

💡 Clinical Pearls

🧠 NICE supports anticipatory prescribing for common symptoms in the last days of life, but drug choice and dose should be individualised.
🔍 For nausea and vomiting, the cause matters: metabolic, chemical, vestibular, raised intracranial pressure, gastric stasis, and bowel obstruction may require different treatments.
🚫 For obstructive bowel disorders with nausea/vomiting, NICE advises considering hyoscine butylbromide first line, and octreotide if symptoms do not improve within 24 hours.
🌬️ Oxygen is not a default treatment for terminal breathlessness; opioids and benzodiazepines may be more relevant depending on the mechanism.

🩺 Syringe Pump Tips

📌 Consider a syringe pump when oral medicines are not possible or tolerated, or when repeated PRN doses are needed.
⚗️ Always check compatibility before mixing drugs in a syringe pump.
💊 Cyclizine can precipitate in syringe drivers, particularly at higher concentrations or with some combinations.
👀 Inspect the syringe and line regularly for cloudiness, crystallisation, or precipitation.

📌 Renal Impairment

⚠️ Opioid prescribing becomes more complex in significant renal impairment because some drugs or metabolites can accumulate.
📞 Seek specialist palliative care or local guideline advice for opioid choice and conversion in severe renal impairment.
🧾 Do not present renal-prescribing rules as universal without reference to local palliative formulary guidance.

🧠 Teaching Pearl

💡 In the last days of life, the goal is comfort through individualised symptom control.
💡 NICE supports anticipatory prescribing, regular reassessment, and early use of continuous SC infusion when repeated PRN dosing is needed — but exact drug doses and combinations usually come from local specialist palliative care guidance or the BNF, not from NICE NG31 itself.

🔑 Principles of End-of-Life Prescribing

👩‍⚕️ Assess symptoms regularly and titrate to effect using the lowest effective dose.
💉 If oral medicines are not possible or not tolerated, the subcutaneous (SC) route is commonly used; avoid intramuscular injections.
📈 If more than 2 or 3 PRN doses are needed in 24 hours, consider a syringe pump / continuous SC infusion.
🩺 In significant renal impairment, opioid choice becomes more complex — seek local palliative guidance / specialist advice.
🤝 Prescribing should be individualised and supported by clear communication with the patient, family, and MDT.

📊 Commonly Used End-of-Life Medicines

💊 Drug	✅ Common indication(s)	💉 Common SC PRN dose	🔄 Common CSCI / syringe pump dose over 24 h	⚠️ Notes
Morphine	Pain, breathlessness	2.5–5 mg SC PRN	Varies by prior opioid exposure; in opioid-naive dying patients some UK guidance uses 5–10 mg/24 h	Avoid or use extreme caution in eGFR <30 because active metabolites accumulate.
Oxycodone	Pain, sometimes breathlessness when morphine unsuitable	Often 1.25–2.5 mg SC PRN	Individualised according to prior opioid dose	Used with caution in renal impairment; conversions are not interchangeable 1:1 with morphine.
Fentanyl	Pain / breathlessness in severe renal impairment	25 micrograms SC PRN	Specialist / local conversion required	Often preferred over morphine in advanced renal failure.
Alfentanil	Pain in severe renal impairment	Local specialist guidance required	Commonly used via syringe pump with specialist input	Very useful in severe renal impairment, but dosing is highly conversion-dependent.
Midazolam	Agitation, anxiety, terminal restlessness, breathlessness with distress, seizures	2.5–5 mg SC PRN	Commonly 5–20 mg/24 h, adjusted to response	Short-acting benzodiazepine; lower starting doses may be needed in frailty or renal impairment.
Haloperidol	Delirium, agitation, nausea/vomiting (especially chemical or opioid-related)	0.5–1 mg SC PRN	Commonly 1.5–5 mg/24 h	Useful if delirium is prominent; watch for extrapyramidal effects and QT prolongation.
Levomepromazine	Refractory nausea/vomiting, agitation	2.5–5 mg SC PRN	Commonly 6.25–12.5 mg/24 h initially	Broad-spectrum antiemetic; sedating, especially at higher doses.
Metoclopramide	Nausea/vomiting due to gastric stasis	10 mg SC PRN	Commonly 30–60 mg/24 h	Best for impaired gastric emptying; avoid in complete bowel obstruction.
Cyclizine	Nausea/vomiting, especially vestibular or raised ICP-type patterns	25–50 mg SC PRN	Commonly 100–150 mg/24 h	Check syringe driver compatibility carefully — may precipitate with some mixtures.
Glycopyrronium	Noisy respiratory secretions	200 micrograms SC PRN	Commonly 600–1200 micrograms/24 h	Often preferred if delirium/confusion risk because it crosses the BBB less.
Hyoscine butylbromide	Respiratory secretions, colicky pain, bowel obstruction	20 mg SC PRN	Commonly 60–120 mg/24 h	NICE recommends it first-line for nausea/vomiting in obstructive bowel disorders.
Hyoscine hydrobromide	Respiratory secretions	Usually local guidance	Local guidance	Alternative antisecretory agent; may cause more CNS effects than glycopyrronium.
Octreotide	Persistent vomiting in malignant bowel obstruction	Usually specialist / local guidance	Commonly introduced if hyoscine butylbromide is insufficient	NICE advises considering octreotide if symptoms do not improve within 24 h of hyoscine butylbromide.

💡 Practical Pearls

🧮 If already on a regular opioid, the SC breakthrough dose is often about 1/6th of the total 24-hour opioid dose after appropriate conversion.
🚽 Opioids commonly cause constipation, so laxatives are usually prescribed unless inappropriate.
👀 Review the effect of PRN doses frequently; if repeated doses are needed, convert to a 24-hour syringe pump.
⚗️ Always check syringe pump compatibility before mixing drugs together.
🧠 For agitation, always think of reversible causes such as pain, urinary retention, constipation, or delirium.

📌 Renal Impairment Summary

🚫 Morphine: avoid or use with great caution in advanced renal impairment.
⚠️ Oxycodone: use cautiously; start low and titrate carefully.
✅ Fentanyl / Alfentanil: commonly preferred in severe renal impairment.
☎️ If eGFR <30, seek local palliative care guidance or specialist advice for opioid choice and conversion.

🧠 Teaching Pearl

💡 NICE gives the principles of anticipatory prescribing, but the exact bedside doses usually come from UK palliative care formularies, regional guidelines, and the BNF.
💡 Always tailor doses to frailty, prior opioid exposure, renal function, and symptom burden.

📚 References

The content on this website is provided for educational and informational purposes only to support exam preparation (e.g., MLA, MRCP, USMLE) and learning. This is NOT medical advice, diagnosis, treatment, or professional guidance. It does not replace consultation with a qualified healthcare professional, official guidelines (e.g., NICE, GMC, BNF), or supervised clinical practice. Always verify information with current, authoritative sources. Makindo and its contributors accept no liability for any reliance on this content, including errors, omissions, or any resulting harm, loss, or consequences. By using this site, you agree to these terms.

End of Life Care Prescribing ✅

🔑 Principles of End-of-Life Prescribing

📊 Anticipatory Prescribing: Symptom Areas

💡 Clinical Pearls

🩺 Syringe Pump Tips

📌 Renal Impairment

🧠 Teaching Pearl

🔑 Principles of End-of-Life Prescribing

📊 Commonly Used End-of-Life Medicines

💡 Practical Pearls

📌 Renal Impairment Summary

🧠 Teaching Pearl

📚 References

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