Anticipatory prescribing

In all patients the following should be prescribed 'when required' on HEPMA or the inpatient prescription chart. For patients with stage 4-5 acute or chronic kidney disease, refer to Renal Disease in Last Days of Life guideline.

Table 1: Anticipatory subcutaneous medications - initial dose suggestions

Symptom Initial dose suggestion

Pain
  • If patient is receiving oral morphine or on a step 2 analgesic (including co-codamol 30/500mg or equivalent) an appropriate SC breakthrough dose of morphine should be available (1/6th to 1/10th of 24 hour equivalent dose).
  • If opioid naïve, consider morphine SC 2mg hourly as required (max 6 doses in 24 hours). N.B. If ≥3 doses are required within 4 hours with little or no benefit, seek urgent advice or review. If >6 doses are required in 24 hours, seek advice or review.

Nausea and vomiting
  • If patient is receiving an oral anti-emetic and this is effective, then that drug should be available for SC use.
  • If patient is not on an anti-emetic, consider levomepromazine SC 2.5mg (TWO point FIVE milligrams) 12 hourly as required. N.B. Levomepromazine can prolong QT interval. See note below.

Anxiety / distress

Prescribe midazolam SC 2mg hourly as required for anxiety / distress (max 6 doses in 24 hours). N.B. If ≥3 doses are required within 4 hours with little or no benefit, seek urgent advice or review. If >6 doses are required in 24 hours, seek advice or review.

Agitation / delirium

Prescribe haloperidol SC 500micrograms 2 hourly as required (max 5mg in 24 hours). N.B. Haloperidol can prolong QT interval. See note below.

Breathlessness (dyspnoea)
  • If patient is receiving oral morphine or a step 2 analgesic (including co-codamol 30/500 or equivalent) an appropriate SC breakthrough dose of morphine should be available (1/6th to 1/10th of 24 hours equivalent dose).
  • If opioid naïve, consider morphine SC 2mg hourly as required (max 6 doses in 24 hours). N.B. If ≥3 doses are required within 4 hours with little or no benefit, seek urgent advice or review. If >6 doses are required in 24 hours, seek advice or review.
  • If patient is breathless and anxious, consider using midazolam SC 2mg hourly as required (max 6 doses in 24 hours). N.B. If ≥3 doses are required within 4 hours with little or no benefit, seek urgent advice or review. If >6 doses are required in 24 hours, seek advice or review.

Respiratory secretions

Prescribe hyoscine butylbromide SC 20mg hourly as required (max 6 doses in 24 hours).

If the patient is reaching maximum dose of any anticipatory medicines then seek advice from the Palliative Care team.

For further information on anticipatory prescribing see the Scottish Palliative Care guidelines.  

Haloperidol and levomepromazine can prolong QT interval. Contraindications to haloperidol include: patients with prolonged QTc interval and in combination with other drugs that prolong QT interval. Where possible modifiable risk factors for QT interval prolongation should be minimised e.g. discontinue other drugs known to prolong QT interval. There may be certain circumstances when it may be used despite contraindications (e.g. distressed individual with an incurable condition at the end of life). Seek senior advice before prescribing. 

A list of drugs which prolong QT interval can be found at http://crediblemeds.org and further information can also be found in the Drug-induced QT Prolongation guideline.
Guideline reviewed May 2023
Page updated June 2023



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