Anticipatory prescribing

Anticipatory prescribing for potential new or worsening symptoms in the last days of life helps manage symptoms more effectively and can avoid a crisis or unplanned transfer to hospital. Anticipatory prescribing includes ensuring drugs and equipment that are likely to be needed are readily available, with prescriptions and drug charts written in advance and supplies obtained.

When prescribing drugs in advance for the last days of life:

if possible, anticipate the likelihood of specific symptoms developing and prescribe drugs for these symptoms
follow the principles of drug therapy for symptoms in the last days of life
include the indication for each drug on the prescription and drug chart (eg opioid for pain or distress associated with breathlessness, benzodiazepine for agitation or restlessness, antiemetic for nausea or vomiting)
consider factors influencing medication management, including location of care, cost and availability of drugs and equipment, safety of drugs in the home and who will be available to administer drugs; for guidance on assisting patients and carers with medication management, see Assisting patients and carers with medication management in palliative care.

Drugs for anticipatory prescribing for the last days of life provides a list of the commonly used drugs for anticipatory prescribing.

Table 1. Drugs for anticipatory prescribing for the last days of lifePrintable PDF
morphine midazolam clonazepam haloperidol metoclopramide glycopyrronium hyoscine butylbromide
Indications	Formulation used in palliative care	PBS [NB1]	PBS Prescriber bag [NB2]
morphine [NB3]
pain breathlessness causing distress	morphine hydrochloride injection 10 mg/mL, 20 mg/mL	yes	yes
pain breathlessness causing distress	morphine sulphate injection 10 mg/mL, 15 mg/mL, 30 mg/mL	yes	yes
midazolam
breathlessness causing distress agitation and restlessness seizures	injection 5 mg/mL, 15 mg/3 mL	no	yes
clonazepam [NB4]
breathlessness causing distress agitation and restlessness seizures	oral drops 2.5 mg/mL (0.1 mg/drop)	yes	yes
	injection 1 mg/mL	yes	no
haloperidol
nausea and vomiting agitation and restlessness	injection 5 mg/mL	yes	yes
metoclopramide
nausea and vomiting	injection 10 mg/2 mL	yes	yes
glycopyrronium [NB5]
respiratory tract secretions	injection 0.2 mg/mL	no	no
hyoscine butylbromide [NB5]
respiratory tract secretions	injection 20 mg/mL	yes	yes
Note: PBS = Pharmaceutical Benefits Scheme NB1: Indicates availability on the PBS Palliative Care Schedule at the time of writing; see the PBS website for current information. NB2: Indicates availability on the PBS Prescriber Bag at the time of writing. Drugs listed on the PBS Prescriber Bag are provided to prescribers without charge; see the PBS website for current information. NB3: Morphine is the opioid of choice in the last days of life; if morphine is contraindicated (eg severe kidney impairment), use an equivalent dose of an alternative opioid; see Choice of opioid in palliative care for factors influencing opioid choice, and Approximate equianalgesic doses of opioids in palliative care for equianalgesic doses. NB4: Clonazepam may be adsorbed onto PVC infusion tubing; non-PVC tubing is recommended or adjust the dose to effect. NB5: Anticholinergic drugs may be used to reduce the production of respiratory secretions and manage rattly breathing in patients in the last days of life. However, there is limited evidence to support this practice, and it is unlikely that patients experience distress from this symptom.