Palliative Care Wales
Anticipatory Prescribing

When a patient with end-stage advanced cancer (or other terminal illness) deteriorates acutely at home with symptoms like pain or breathlessness, it may be their wish to remain at home and be treated palliatively. The delay of waiting to see an out-of-hours doctor, and then to find a chemist open which stocks the drugs can be extremely distressing for both patient and their family.

Two methods of anticipating these situations are the Just in Case scheme, and a more individualised type of anticipatory prescribing, known as “Targeted Anticipatory Prescribing”. Both of them aim to optimize end-of-life care for patients at home, and may help to prevent unnecessary admissions to hospital.

Suitable patients may be identified at regular palliative care meetings in the GP practice, or by the specialist palliative care teams. Anticipatory prescribing can be considered as part of Advance Care Planning for the patient.

Just in Case Box

The Just in Case scheme is an All-Wales scheme which has been approved by the Welsh Assembly Government. An orange bag with standard contents can be prescribed on WP10 and dispensed from participating community pharmacies. It contains injectable drugs for common symptoms such as pain, breathlessness, anxiety or agitation, and is suitable for palliative care patients in the last months of their life.

The box contains enough drugs to achieve initial symptom control or to last overnight, but additional drugs may be needed if a syringe driver is required, or to cover a weekend. In cases where patients are already on significant doses of opioids, or when the circumstances of their likely deterioration can be anticipated, a more individualised approach to prescribing  is appropriate.

Example 1

You are looking after a patient with bowel cancer. She is receiving palliative chemotherapy but her condition is slowly deteriorating. You feel that her prognosis is likely to be only a few months.
On discussion with her it is clear that she is frightened of being in pain (which she does not currently have), and that quality of life is her priority. She wishes to remain at home “at all costs”, and is realistic about her prognosis.
You should consider prescribing the Just in Case bag, and a drug authorisation for PRN administration.

Example 2

A patient with NYHA Stage IV heart failure has been told by his cardiologist that there is little more they can do to help his condition. You estimate his prognosis to be less than 6 months, but probably more than a few weeks. He has said that he does not want to go into hospital unless it is absolutely necessary.
During his last admission to hospital he had a chest infection treated with antibiotics, and the patient would not rule out further active treatment if it is appropriate.
You consider that it is quite possible that this patient will deteriorate, and this could happen fairly acutely out-of-hours in circumstances where palliative control of his symptoms at home would be appropriate. You should consider prescribing a Just in Case bag, which would reduce delay in accessing injectable drugs for pain or breathlessness.
However you may decide to annotate the drug chart to instruct the nurse to contact GP before administering a first dose, as it is difficult to anticipate the circumstances in which they may be needed.

Prescribing a Just in Case bag

See below for more information about the Just in Case scheme.

Targeted Anticipatory Prescribing

If a patient is considered to be in the last few weeks or days of life, you should ensure that there is PRN medication available in the home to control pain, breathlessness, vomiting, anxiety/agitation, and death rattle. This will usually be covered by prescribing diamorphine (or alternative), cyclizine, midazolam and hyoscine hydrobromide for PRN SC injection. You should also consider any other predictable complications specific to the patient e.g. seizures or colic.

The quantity tables (below) suggest appropriate quantities to prescribe to cover a 3 day period (Friday night to Monday morning).  Larger quantities should be prescribed before Bank Holiday weekends, Easter, Christmas breaks etc.

Example 3

A patient with metastatic lung cancer is deteriorating rapidly and he is keen to stay at home. He is taking M.S.T 30mg b.d. and cyclizine 50mg t.d.s. You estimate his prognosis to be less than a few weeks. He is still just managing to take his oral medication at present.
As it is likely that he will need a syringe driver in the near future, and you can anticipate his likely needs, you should consider prescribing drugs needed for a syringe driver as well as PRN drugs for end-of-life care (targeted anticipatory prescribing).
Suitable drugs to prescribe for a syringe driver would be based on his current needs:
- diamorphine 20mg/24hr and
- cyclizine 150mg/24hr
Suitable PRN medication would be:
- diamorphine 5mg SC PRN 4-hourly (based on 24hr dose) - pain or breathlessness
- cyclizine 50mg SC PRN 8-hourly - nausea & vomiting
- midazolam 2.5-5mg SC PRN 4-hourly -  anxiety / agitation
- hyoscine hydrobromide SC PRN 0.4mg 4-hourly -  death rattle
To determine the quantities to prescribe, look at the tables which follow and refer to the regular daily dose in the left  column. Unless there is a Bank Holiday looming, prescribe for 3-days to cover a weekend:
- diamorphine (daily dose=20mg)  10mg ampoules x15
- cyclizine (daily dose=150mg) x15 ampoules (50mg/1mL)
- midazolam (daily dose=nil) x10 ampoules (10mg/2mL)
- hyoscine hydrobromide (daily dose=nil) x20 ampoules (0.4mg/1mL)
These quantities are sufficient to provide for both a syringe driver and PRN doses for 3 days.