End of life care planning and medicines optimisation

Care planning and communication are central to safe management of medicines for people during care at the end of their life.

Prescribing for people at the end of their life can take place in their own homes, care homes, and in community inpatient and acute hospital settings. Medicines can be prescribed by a doctor or by non-medical prescribers, such as nurses, paramedics, pharmacists or other allied healthcare professionals working in end of life care and are appropriately qualified.

Anticipatory prescribing

This is the prescribing and dispensing of injectable medicines for a named person, before there is a clinical need, for administration by suitably trained individuals if symptoms arise in the final weeks and days of life.

All other prescribed medicines should be reviewed at the same time.

See NICE guidance Care of dying adults in the last days of life

Care providers should be aware of any local schemes to access anticipatory medicines. This includes outside of normal working hours.

If medicines are supplied in advance of need there must be personalised administration directions from the prescriber (authorisation to administer) before they can be administered. Administration directions for a medicine can be a sliding scale with allowed incremental dose adjustments. The record of administration shows the dose given. The authorisation sheet will say how many doses can be given before review by a prescriber is required (usually 3 doses).

The authorisation sheet should only be valid for a defined period.

Healthcare professionals from outside the care home may visit to administer medicines. Care home staff should keep a record of medicines administered by those professionals, and they must update controlled drug registers when controlled drugs are given.

A record of the quantity of medicines in a person’s home should be kept, in line with local policy.

In the last days of life

In the last days of a person’s life, their current medicines will be reviewed by a healthcare professional involved in their care. Before stopping or changing any medicines, options should be discussed with the person or their carer or relative.

A person’s ability to take medicines by mouth is reduced in the final weeks and days of life. This means that it may be necessary to change the route of administration for medicines that are to be continued, such as those for epilepsy or Parkinson’s disease.

Decisions made should be recorded in the care plan. The care plan should also include oral health care needs.

Symptom control

Anticipatory medicines are administered to give rapid relief from symptoms when needed and prevent distressing hospital admissions.

See: Care of dying adults in the last days of life

Medicines are usually prescribed to manage pain, nausea and vomiting, secretions and agitation. These can include controlled drugs.

If 'when required' PRN medicines are prescribed, it must be clear what they are being used for. For example, you could use morphine sulphate oral solution for pain or breathlessness. Clear guidance should be in place and reviewed as needed.

Staff should record the dose of PRN medicine given and whether it is effective. Initially, medicines may be prescribed and administered when required, but there should be a regular review.

Find out more about PRN medicines.

Syringe drivers

Syringe drivers are used to administer medicines subcutaneously. They may benefit patients who are unable to take oral medicines. In some cases, the local hospice can help with syringe drivers.

Where nurses are providing care (such as in a nursing home), they should:

• check that medicines and solutions used to dilute them are compatible. Use a recognised source to check compatibility
• use 2 separate syringe drivers if compatibility is an issue
• check that syringe drivers are adequately maintained
• be trained and competent before using a syringe driver
• be familiar with local policies, procedures and the pump used.

Once the syringe driver has started, it should be labelled and regularly checked in line with local policy. Medicines should be reviewed daily, including additional ‘when required’ doses administered over the previous 24 hours. If the need for a PRN medicine is becoming more frequent, dosing should be switched to a syringe driver.

The care plan should make it clear who to contact for help, including out of hours.

Controlled drugs

There should be robust procedures for safe and secure storage of a person's medicines and the disposal/return of any unused medicines. The processes should limit access to medicines to appropriate people. This is particularly important when dealing with controlled drugs. Keep appropriate and accurate records.

Care at home

Before storing medicines in a person’s home, providers should carry out a risk assessment. There is no legal requirement for controlled drugs to be treated differently or stored separately from other medicines.

Find out more about keeping controlled drugs in a person’s home.

Care homes

Controlled drugs must be stored securely, and registers must be maintained.

Find out more about storing controlled drugs in care homes. 

In care homes, it is good practice for 2 nurses or members of staff to check and administer controlled drugs. This is not a legal requirement. Where staff do the second check, they should be trained and assessed as competent.

You should have robust systems in place to review incidents. Report and respond to any discrepancies within reasonable time limits. Policies should include the name and contact details of anyone who you need to inform. Include details of the relevant NHS Controlled Drugs Accountable Officer (CDAO) at NHS England.