Anticipatory Prescribing & Comfort Care
Anticipatory prescribing means having medications ready before they are needed, so that symptoms can be managed promptly when they arise. This is a key part of good end of life care — it prevents delay in relieving pain, agitation, nausea, and respiratory secretions.
Why Anticipatory Prescribing Matters
When a person is dying, symptoms can develop quickly. Without anticipatory prescribing, there can be delays of hours before a doctor prescribes and a nurse administers the medication — during which the person may experience unnecessary distress. NICE guideline NG31 recommends that anticipatory medicines are prescribed for people who are likely to need symptom control in the last days of life.
- Anticipatory prescriptions should be in place before the dying phase, based on likely symptoms
- All nursing staff must know which anticipatory medications are prescribed and how to administer them
- Medications must be stored safely and checked regularly to ensure they are in date and available
- The GP or palliative care team should review anticipatory prescriptions regularly
Common Anticipatory Medications
The following medications are commonly prescribed as anticipatory (PRN) medications for end of life symptom management. Doses are typical starting ranges — always follow the individual prescription and the prescriber's instructions.
| Medication | Indication | Route | Notes |
|---|---|---|---|
| Diamorphine (or Morphine) | Pain and breathlessness | SC injection or syringe driver | For opioid-naïve patients, start at low dose (e.g., diamorphine 2.5–5mg SC 4-hourly PRN). Monitor for sedation and respiratory depression. |
| Midazolam | Agitation, restlessness, seizures | SC injection or syringe driver | 2.5–5mg SC PRN. Can also be given via buccal route. Particularly useful for terminal agitation not responding to non-pharmacological measures. |
| Glycopyrronium (or Hyoscine butylbromide) | Respiratory secretions ('death rattle') | SC injection or syringe driver | 200mcg SC 4–6 hourly PRN. Must be given early for best effect — once secretions are established, effectiveness is limited. Reposition the person on their side. |
| Levomepromazine | Nausea and vomiting, also agitation | SC injection or syringe driver | 2.5–5mg SC PRN for nausea. Higher doses (12.5–25mg) can be used for agitation. Has sedative properties. |
| Metoclopramide or Cyclizine | Nausea and vomiting | SC injection | Alternative to levomepromazine. Cyclizine 50mg SC 8-hourly. Metoclopramide is not suitable for bowel obstruction. |
Important:Only nurses who are trained and competent to administer subcutaneous (SC) injections should do so. All medication administration must be in accordance with the prescription, the care home's medication policy, and the NMC Code. Never administer medication if you are unsure about the dose, route, or indication.
Syringe Driver Overview
A syringe driver (or syringe pump) is a small, portable device that delivers medication continuously under the skin (subcutaneously) over a set period — usually 24 hours. It is commonly used in end of life care when a person can no longer swallow oral medication, or when multiple medications need to be given via a continuous infusion.
When a Syringe Driver Is Used
- When the person is unable to swallow (e.g., semi-conscious, vomiting, or unable to absorb oral medication)
- When multiple subcutaneous medications are needed — a syringe driver reduces the number of injections
- To maintain steady blood levels of medication for consistent symptom control
Key Considerations
- Not all medications are compatible in the same syringe — check compatibility charts or consult a pharmacist
- The site should be checked regularly for inflammation, leakage, or discomfort — rotate the site if needed
- A syringe driver should be set up and checked by a nurse trained in its use
- Explain to the person and their family what the syringe driver is for — it is not “giving up” but ensuring comfort
Comfort Care Measures
Alongside medication, these comfort measures are essential to ensure the person's dignity, relieve distress, and support their family. Good comfort care is as important as good medical management.
Physical Comfort
- Regular mouth care — moisten lips with swabs, offer small sips of water if safe to swallow
- Position for comfort — on the side with pillows for support if unable to sit up
- Keep the person clean and dry — gentle personal care
- Manage pain proactively — assess using appropriate tools
- Ensure the room is a comfortable temperature and well-ventilated
- Reduce unnecessary interventions (e.g., routine observations if they cause distress)
- Use a syringe driver if multiple SC medications needed — reduces injection frequency
- Consider catheterisation only if urinary retention is causing distress
- Gentle massage with unscented lotion can be soothing
Emotional and Spiritual Support
- Be present — sit with the person, hold their hand if appropriate
- Speak gently and reassuringly — hearing is thought to be the last sense to go
- Play the person's favourite music softly
- Read aloud from a preferred book, prayer, or religious text
- Facilitate visits from family and important people
- Support the person's spiritual or religious practices
- Create a calm, peaceful environment — dim harsh lighting, reduce noise
- Acknowledge and validate family members' feelings
Supporting Family and Carers
- Explain what is happening and what to expect — demystify the dying process
- Encourage family to talk to and be with the person
- Offer refreshments and a private space for family
- Provide written information about the dying process
- Discuss after-death arrangements sensitively if the family wishes
- Offer referral to bereavement support services
- Ensure family know who to contact for support after the death
Official Resources
⚠️ Important Notice
The anticipatory prescribing information on Care Handbook is for informational purposes only and does not constitute medical, nursing, or prescribing advice. All medication must be prescribed by a qualified prescriber and administered by a competent, trained professional in accordance with the prescription and your care home's medication policy. Always consult the GP, district nurse, or palliative care specialist for clinical decisions.