Anticipatory Medicines

End-of-life prescribing — just in case box & syringe driver

Prescribe four SC PRN medications before the patient needs them — don't wait for symptoms. Anticipatory medications allow nurses to respond immediately. Initiate syringe driver when >2 PRN doses used in 24 hours.

What to do

1 · Recognise dying

Bedbound, sips only, altered consciousness, mottling, Cheyne-Stokes breathing, peripherally shut down. If uncertain — senior + palliative team input.

2 · Communicate with family

Explain: dying is happening, focus is comfort, what symptoms may arise and how they will be managed. Before prescribing, not after.

3 · Prescribe the just in case box (all SC PRN)

Morphine 2.5mg — pain/breathlessness
Midazolam 2.5mg — agitation
Hyoscine butylbromide 20mg — secretions
Haloperidol 1.5mg — nausea

All PRN 4-hourly.

4 · Review current medications

Stop: statins, antihypertensives, metformin, bisphosphonates, anticoagulants (unless symptom-related).

Continue: anti-seizure drugs, steroids (if reducing symptoms).

5 · Syringe driver if >2 PRN doses

Convert 24h PRN use to CSCI (continuous SC infusion). Add 1/6 of total as breakthrough PRN. Involve palliative care team for setup.

6 · DNACPR

Check it is in place and documented. If absent in a dying patient: urgent senior conversation today.

Drugs

Drug	Dose	Route	Notes
Morphine	2.5mg	SC PRN 4-hourly	Opioid-naive. Pain and breathlessness. If on regular morphine: use 1/6 of daily dose as PRN.
Midazolam	2.5mg	SC PRN 4-hourly	Agitation, anxiety, terminal restlessness.
Hyoscine butylbromide (Buscopan)	20mg	SC PRN 4-hourly	Secretions ('death rattle'). Does NOT cross blood-brain barrier — not sedating.
Haloperidol	1.5mg	SC PRN 12-hourly	Nausea, agitation. Low doses only.

Red flags

Patient still conscious and distressed despite 2 doses midazolam — palliative team urgently
Pain not controlled with morphine 2.5mg PRN — increase dose or initiate syringe driver
Noisy breathing distressing family — hyoscine butylbromide + reassure family it does not cause pain
No DNACPR in place — senior must make decision and document today

Reference: NICE NG31 (Care of Dying Adults) / Palliative Care Formulary 6th Ed