Anticipatory medicines in palliative care

It’s common for people to experience symptoms towards the end of life including anxiety, pain, nausea and vomiting, and noisy chest secretions. These symptoms can affect people with many different terminal illnesses and can be very distressing. Medicines to help with these symptoms can be prescribed in advance to make sure they’re ready when they’re needed. This can help people to feel as comfortable as possible towards the end of their lives.

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What is anticipatory prescribing?

Anticipatory prescribing means making sure that someone has access to medicines they will need if they develop distressing symptoms at home or in a care home. The medicines are prescribed in advance so that the person has access to them as soon as they need them. A doctor or specialist nurse prescribes medicines and supplies any equipment such as needles and syringes that are needed to give the medicines.

Not everyone will have these symptoms. The medicines are supplied just in case someone develops symptoms. These medicines can be called anticipatory medicines, end of life medicines, or just in case medicines.

If someone develops symptoms, the person, their family, friends or carers can call their GP, specialist nurse or district nurse. In most cases, the health professional then comes to the person and gives them the medicines they need.

Having medicines in their own home, or care home, means that the health professional can give medicines and get symptoms under control more quickly. It also means that the person is less likely to need to go into a hospital or hospice to have their symptoms managed.

Anticipatory medicines are often given towards the end of life. However, these are all medicines which can be used for symptom management and given at any point in someone’s illness if they need them.

Read more about caring for patients in the last days and hours of life.

What symptoms are anticipatory medicines prescribed for?

Most anticipatory prescriptions include medicines to treat common symptoms. The most common symptoms are:

• pain
• anxiety and distress
• delirium
• breathlessness
• agitation
• nausea and vomiting
• noisy chest secretions.
  

Medicines can also be prescribed for other symptoms including massive haemorrhage (bleeding) and seizures if the person is thought to be at risk of these symptoms.

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Which medicines are prescribed?

Different medicines will be prescribed to meet the needs of different people. Prescribers should consider each person’s individual situation, needs and preferences. Below are some of the medicines that are commonly prescribed. Different medicines might be prescribed in different areas. If you’re a prescriber, you should follow your local guidelines.

Clear instructions for giving each medicine must be written in the community medication administration chart, including dose, route of administration, frequency, indications, limits and when to ask for help.

Common anticipatory medicines include the following:

• Medicine for pain in palliative care – an appropriate opioid, for example, morphine, diamorphine, oxycodone or alfentanil.
• Medicine for breathlessness – midazolam or an opioid.
• Medicine for anxiety – midazolam.
• Medicine for delirium or agitation – haloperidol, levomepromazine, midazolam or phenobarbital.
• Medicine for nausea and vomiting – cyclizine, metoclopramide, haloperidol or levomepromazine.
• Medicine for noisy chest secretions – hyoscine hydrobromide or glycopyrronium.

Some of the medicines can help more than one symptom. For example, levomepromazine can treat delirium or agitation, and nausea and vomiting. Opioids can help with pain, breathlessness and anxiety.

How are anticipatory medicines supplied?

A doctor or specialist nurse will review the patient and prescribe the medicines that they are most likely to need based on their illness and their symptoms. If someone is being discharged from a hospital or hospice, they will usually be given two weeks’ supply of all of their medicines including their anticipatory medicines, unless they already have supplies at home.

If the anticipatory medicines are prescribed by a GP, they might get just a few days of medicines supplied. If the medicines are needed, the GP will usually come to review the person within a couple of days and prescribe more anticipatory medicines if needed.

If someone needs more medicines, the person or their carer will need to take a prescription from their GP to the pharmacy. Not all pharmacies stock anticipatory medicines. Find out which pharmacies in your area stock them. This can save the person’s friends and family time when they go to get the prescription.

Where should anticipatory medicines be kept?

Anticipatory medicines should be supplied with the equipment needed to give them. This includes syringes, needles and sharps containers. All the medicines and equipment can be stored together in a ‘Just in case box’. Make sure that you know where they are stored in your patients’ homes.

It’s important to store medicines safely:

• read the instructions on the label carefully
• check on the label how long they will last once they’ve been opened
• don’t use medicines if they are out of date
• keep them out of the reach or sight of children
• store in a cool, dry place, away from direct heat and light
• some medicines need to be stored in the fridge
• ask a pharmacist if you are unsure about anything.

Abuse of medicines

Some anticipatory medicines are drugs that can be abused and have a high street value. In rare cases, there is a risk of someone close to the person taking the medicines. People may want to steal them to sell or use themselves. This is sometimes called diversion.

It can also be challenging if someone is experiencing homelessness and there isn’t a safe, secure place to store the medicines.

In these cases, the multidisciplinary team should discuss what’s best for the individual. Sometimes professionals visit each day and bring only the medicines that will be needed on that day. Sometimes a locked box is installed to keep the medicines and equipment in, and only the people who are able to give the medicines have access to the key.

When should anticipatory medicines be given?

Anticipatory medicines should be given when the person you’re caring for develops a symptom and they have a medicine prescribed for that symptom. This could be a new symptom for them. Or it could be that they need extra medication to manage it, for example if they are having breakthrough pain even though they are taking regular pain killers. Someone might need to take injectable medicines if they are no longer able to take their medicines orally, for example if they are vomiting or have difficulty swallowing.

Before any medicine is given, it’s important to assess the person and check their care plan.

If you are not trained to give medicines, you should call for help from someone who is in any of these situations. Family and friends aren’t expected to give anticipatory medicines but in rare cases there may be training and policies to support this.

What happens next?

If anticipatory medicines are given, the person’s GP or specialist nurse should review the person, their symptoms and their regular medicines. They might need changes to their regular medicines to manage their symptoms. Sometimes, the best way to manage symptoms is to give continuous injectable medicines through a syringe driver.

How can I support someone with anticipatory medicines?

If you’re caring for someone towards the end of their life, there are lots of things you can do to support them and help them to get the right medicines if they need them for managing symptoms. You can:

• find out if the person has anticipatory medicines
• know where they’re kept so you can get to them quickly if they’re needed
• know when to give anticipatory medicines
• know who to ask for help, especially if you’re not trained to give medicines
• talk to the person and those around them to help them understand how anticipatory medicines can help.

Talking about anticipatory medicines

Good communication is very important to help people understand why anticipatory medicines are prescribed. Some people can feel reassured to know that medicines are available if they develop distressing symptoms.

Lots of people have concerns about anticipatory medicines. It’s important to reassure them that these medicines are prescribed just in case they’re needed. Not everyone will need them. It can be hard to predict who will develop distressing symptoms so it’s good to have medicine ready to manage them just in case. Having medicines ready means that symptoms can be managed more quickly to keep the person as comfortable as possible. This can be reassuring for the person and those close to them.

All medicines have side effects. Some of the commonly used anticipatory medicines can make people feel drowsy and their breathing may change. It can be helpful to let family and friends know in advance that these are common side effects.

Some health and social care professionals also have concerns about giving end of life medicines. If you are unsure or have any worries, speak to an experienced colleague.

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Useful resources

Scottish Palliative Care Guidelines – Anticipatory Prescribing  

NICE guideline 31 – care of dying adults in the last days of life  

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Disclaimer

This information is not intended to replace any training, national or local guidelines, or advice from other health or social care professionals. 

The Palliative Care Knowledge Zone is not intended for use by people living with a terminal illness or their family and friends, who should access our information for the public.