Palliative Care Guidelines
Jimmy S Bilimoria Foundation



To improve the end of life care, it is useful if medications for end of life symptom control are made available at home so that they can be administered without unnecessary delay, when required. ‘If needed medications’ boxes including the appropriate medications and medication charts with doctor’s signature should be arranged at the appropriate time for the patient’s family. The aim is to provide enough parenteral medication potentially to last for a 48-72 hour period to avoid unnecessary hospital admissions and promote patients’ choice of preferred place of care.


  • The patient should be assessed clinically by an experienced clinician and the following conditions should be established before administering anticipatory medications:
    • Irreversibility of the patient’ s condition/that patient is at the end of life
    • Inability to take oral medications
    • Informed consent
  • Doctors should write anticipatory prescriptions keeping in mind what is likely to be needed by patient
  • Anticipatory prescribing should be designed to ‘ensure that there is availability of medications in the patient’s home, combined with technical support necessary to administer them for use after an appropriate clinical assessment’
  • When prescribing anticipatory medications consider the following:
    • The likelihood of symptoms occurring
    • Risks and rewards of prescribing or administering such medications
    • Likelihood of sudden deterioration (e.g. catastrophic haemorrhage or seizures) for which urgent symptom control may be required
    • Time necessary to obtain medications
  • A standard anticipatory prescription should include medication to treat pain, breathlessness, anxiety/distress, nausea, confusion/delirium and respiratory secretions
  • Nurses will have the central role in assessing end-of-life symptoms in dying patients and enabling patient/family timely access and availability to the appropriate medications
  • Nurses should have knowledge and experience with the relevant medications
  • Nurses should be educated and trained in assessment of end-of-life symptoms and the appropriate medications for treating them
  • Anticipatory medications must be provided in ‘if needed medications’ boxes, which also contains syringes and needles
  • The medication chart should have the dose, route, frequency and indication(s)
  • Anticipatory medications should be administered in the subcutaneous route
  • If a patient requires regular doses, a syringe driver should be used to administer medications continuously over a 24-hour period
  • When setting up a syringe driver, a separate prescription should be provided
  • Anticipatory medications should be kept in the home to be used ‘as required’ for breakthrough symptoms when syringe driver is in place
  • Anticipatory medications should be prescribed after checking the available medications at home
  • Anticipatory medications should be monitored and reviewed every 24 hours and the dose should be adjusted if necessary, by the clinician (only)
  • Anticipatory medications should not be provided if there is a risk of drug diversion or abuse


The prescription should include the five medications that might normally be required for end-of-life symptom control, plus diluents. It is important that the wording of the prescription for controlled medications meets the legal requirement to reduce delays in dispensing

Recommended medication for ‘If Needed’ anticipatory prescription
IndicationMedicationRouteDose instructionRecommended supply
Pain*Tramadol injection (50mg/mL ampoules)

*Morphine Sulphate injection (10mg/mL ampoules)
S/CDose to be determined by prescriberSufficient supply to cover ‘Out of Hours’ period or 48 – 72 hours whichever is longer
Breathlessness*Morphine Sulphate injection (10mg/mL ampoules)S/CDose to be determine by prescriber
Morphine 1mg q1h S-C prn in opioid naïve patients
Sufficient supply to cover ‘Out of Hours’ period or 48 – 72 hours whichever is longer
Midazolam injection (5mg/5mL ampoules)S/C2.5-5mg q1h prnTwenty (20) ampoules of 5 mL
Midazolam injection (5mg/mL vials)S/C2.5-5mg q1h prnTwenty (20) ampoules of 1mL
Respiratory secretionsHyoscine butyl bromide injection (20mg/mL ampoules)S/C20mg q1h prn

Maximum dose – 120mg/24 hours
Ten (10) ampoules of 1mL
Nausea and vomitingHaloperidol injection (5mg/mL ampoules)S/C1.5mg OD or bd hourly as neededFive (5) ampoules of 1mL
Confusion/ deliriumHaloperidol injection (5mg/1mL ampoules)S/C1.5-5 mg OD or bd daily prnFive (5) ampoules of 1mL
* Consider appropriate use of morphine (dose/ frequency) or other opioids like buprenorphine / fentanyl patches if renal failure
  • When transdermal patches are used (fentanyl/ buprenorphine) this can be continued; and should be kept in place and changed as prescribed. If the patient is unable to swallow, rescue dose of morphine S/C should be prescribed at a dose appropriate to the patch dose in use


  • Adam, J. (2006). The last 48 hours. ABC of Palliative Care. (pp. 44-47)
  • Twycross, R., Wilcock, A., Howard, P. (2014). Pre-emptive prescribing in the community. Palliative Care Formulary 5. (pp. 831-835)

Palliative Care Guidelines