Anticipatory medicines

Anticipate deterioration at home

Most people approaching end of life want to be cared for and die at home. Access to injectable or sublingual medicines, if and when they are needed, is key to comfort and dying at home.

The condition of patients with advanced illness can change rapidly:

• existing symptoms may become worse
• new symptoms may arise
• absorption of oral medications may decrease
• the patient may lose the ability to swallow.

Anticipating deterioration enables carers to be ready if and when something happens.

Common symptoms at the end of life include pain, dyspnoea, nausea and agitation. They can occur at any time. Inability of the carer or community palliative care nurse to relieve them often results in calls for an ambulance, waiting in the emergency department and admission to hospital. This scenario is distressing and exhausting for patients and families and undermines their confidence in managing care at home.

Anticipatory medicines enable prompt symptom relief at whatever time the patient develops distressing symptoms.

Arrange anticipatory medicines

Arrange anticipatory medicines when:

• the patient is in the deteriorating or terminal phase
• there are fluctuating levels of symptom distress
• there are known problems with gastrointestinal absorption
• the patient is expected to lose the ability to swallow soon.

Arrange anticipatory medicines before discharge because:

• patients may need the medicines before they have a chance to see their general practitioner
• some general practitioners see few palliative care and end of life patients and are not confident to prescribe anticipatory medicines such as opioids
• patients often arrive home days before their general practitioner receives a discharge summary. General practitioners are understandably reluctant to prescribe injectable medicines in the absence of sufficient information about the patient’s condition
• the patient may need anticipatory medicines overnight, on a weekend or public holiday when few general practitioners or pharmacies are available
• locum general practitioners will have limited knowledge of the patient's history.

Anticipatory medicines commonly include:

• injectable form of the opioid being taken orally
• injectable anti-emetic
• sub-lingual clonazepam drops or injectable midazolam.

Northern Health Palliative Care Service and West Gippsland HealthCare Group have shared resources that guide prescribing anticipatory medicines.

Summary guideline for management of symptoms at the end of life - Northern Health Palliative Care Service
Anticipatory medicines guidelines - West Gippsland HealthCare Group

Take into account:

• your patient's specific requirements - for example, age, allergies. and medical conditions such as kidney or liver impairment.
• the requirements of your health service.

Advise specialist community palliative care service of the anticipatory medicines as part of your referral process.

Catastrophic orders

'Catastrophic orders' are medical orders written in preparation for a likely catastrophic terminal event. More information about catastrophic orders is in Referring to the community.

Anticipatory medicines pack

Provide the means to administer anticipatory medicines with a pack that includes:

• medicines
• orders
• needles for drawing up and administering medicines and syringes
• alcohol swabs
• sharps disposal.

Coaching the patient and carer

Having injectable medications in the home may be challenging for the patient and carer, especially if the patient has not needed injections before. It can be useful to explain that:

• the medicines support the patient's wish for care at home
• the medicines are a form of insurance - they may never be needed but they might prevent distress and a trip to hospital
• the community palliative care service usually administers them
• in some circumstances, carers can be trained to administer them.

Give examples of when they might be used.

Advise the patient and carer to:

• store the anticipatory medicines pack in a cool place and out of reach of children
• show the pack to the nurse from the specialist community palliative care team
• record the time, date and dose of administration (if they have been trained to do this themselves).