Palliative Care - Top Tips - GHFT

Please do this early, better to have them in the house weeks before needed than not at all and cost effective overall.

What it says on the white symptom control drug chart:

a. Diamorphine 2.5mgs-5mgs 1 hrly prn sc

b. Levomepromazine 6.25mg 6hrly prn sc

c. Midazolam 2.5-5mgs 30 mins prn sc

d. Glycopyrronium 200-400mcg 4 hrly prn sc

e. Only put antiemetic in driver if N and V a problem or opioid naïve

f. Keep analgesic patch on if one in place, add in driver for topping up, other meds and prns – flow chart on pall care webpages.

  • More research encouraging their use than benzodiazepines, even non-malignant
  • Any opioid – BuTrans patches good as doses are low
  • Avoid constipation – even more miserable when breathless
  • Antiemetics only as you start them, no permanent need.
  • SOB at EOL: 10mgs Diamorph and 10mgs Midazolam.
  • Guidance on intractable breathlessness available here

It is still a medical decision – The Court of Appeal made it much more of a big deal that we discuss it with each patient unless very good reason not to i.e. demonstrable psychological distress and ensure this is documented…



  • ‘would you like to be resuscitated?’


  • ‘a resuscitation attempt when your heart has stopped because of cancer / heart failure / COPD highly unlikely to work and would not return you to how you are now, would only prolong the dying phase’

Patient should be informed of decision but not making the decision.

'What is in the clinic letter' may not be what the patient understands...


  • 'What is your understanding of all this?'
  • 'What are your expectations with this illness?'
  • 'When you look ahead, what sort of thing comes to mind?'

Capture that conversation - any way will do!

  • Often helpful to focus on unacceptable outcomes but be specific: i.e. 'I do not wish to be forcefed'...
  • Avoid hospital admission if at all possible
  • IV antibiotics, tube feeding, resus
  • Write it down; a letter, the ACP green booklet, Out of Hours Computer Systems...
  • Share the decisions with acute sectors

  • Living with uncertainty is difficult but it is not depression
  • Or is it?
  • You are the best judge as you knew them before they were ill
  • Criticism for under-use of antidepressants in palliative patients

Please review meds early into metastatic disease process or once signing DS1500

  • Anti-hypertensives e.g. Amlodipine, Doxazosin
  • Statins: NNT for benefit to patient when prognosis 6/12 is very, very high
  • Keep things that will help symptomatically e.g. anti-anginals, diuretics, Digoxin
  • 3 years Alendronic Acid now felt to have given lifetime benefit anyway

Please Contact the Palliative Care Team- GHFT:

  • On call for telephone advice 24/7, 365 days a year.
  • Nurse on triage
    • 0300 422 5370 in working hours
    • 0300 422 2222 OOH and ask for on-call CNS.

Useful websites

'Just in Case' Boxes

'Just in Case' boxes are currently available in the Forest of Dean and contain the patient's customised anticipatory medications as prescribed by their doctor.

Please see 'Not in the Forest of Dean' section if you are not in Forest of Dean but want to prescribe 'Just in Case' boxes.

  • 'Just in case' boxes are widely used across the UK
  • Cost effective
  • Evidenced as 'best practice' in the Gold standard Framework for End of Life care
  • Reduce calls to OOHs/on-call pharmacists and reduce hospital admissions
  • Enable patients to access end of life medications 24/7, improving symptom control
  • Well received by patients and their families

Reduce the time taken for community nurses to complete stock checks of the patient's anticipatory medications
  • Where possible use medications with at least 6 months before expiry

  • Can be used for a syringe driver if clinically indicated

Any adult patient in the Forest of Dean locality who may be in the last 6 months of life

Don't wait until the patient is in the terminal phase of their illness. Consider prescribing a 'Just in Case' box when the patient's condition is starting to deteriorate (last few weeks to months)

If there is a history or suspicion of drug misuse among carers or visitors to the house or patient is unable to store safely from children it may be more appropriate to have a "locked box" instead (assess risk on an individual basis).

'Just in Case' boxes can obtain any prescribable medication the patient may require in their last few days of life.

"For a JICB" can be written on the FP10 or put in the 'Script notes' box when prescribing. Please make it clear if any of the items on the FP10 are not to go inside the 'Just in Case' box. The FP10 can be taken to any pharmacy in the Forest of Dean.

There will be occasions when you will need to prescribe alternative medications/quantities for a patient's 'Just in Case' box e.g. for a patient in renal failure, if they are already on high doses of opioids or they have known drug allergies.

Suggested medications for a 'Just in Case' box where a patient is on no routine medication:

  • Diamorphine 5mg x 5 ampoules
  • Midazolam 10mg in 2ml x 5 ampoules
  • Levomepromazine 25mg/1ml x 5 ampoules
  • Glycopyrronium 200micrograms/1ml x 5 ampoules
  • Water for injection 10ml x 5 ampoules 

Remember to:

  • Complete the Summary Care Record with any advance care planning/DNAR discussions and tick the 'anticipatory medication prescribed' box
  • Inform the local community nursing team . They will collect the drug chart from the surgery, stock check the medications and make syringes and needles available in the patient's home.
  • Review the anticipatory medications regularly/if the patient's condition changes to ensure they are still appropriate. Sign prescriber review sticker on the outside of the box whenever you do this.

The box may be opened and medication adminsitered by a community nurse, doctor or registered medical practitioner. The 'Just in 'Case' box medications may be used in a syringe driver if clinically indicated. If you open a 'Just in Case' box please inform the community nursing team.


Once the box has been opened further stock will not be issed as a 'Just in Case' box but can be stored in the original unsealed 'Just in Case' box. Prescribe replacement stock but do not mark FP10 as a 'Just in Case' box.

Please ask the patient or family to return the box to the pharmacy/dispensary who will check the contents. If the box is damaged they will repack the medications in a new 'Just in Case' box. If opened in error they will reseal the original box. If the medications are damaged a new prescription will be required.

Please ask the patient or family to return the box to the pharmacy/dispensary with the prescription for the new medication which can be dispensed and added to the 'Just in Case' box.

We are working hard with local pharmacies to ensure timely access to end of life medications. If you are experiencing difficulties in accessing end of life medications please feedback to .Prescribing early, before the patient enters the last few days of life, can help prevent patients experiencing delays.

If the ' Just in Case' box and medications are no longer needed they should be returned to the pharmacy by the family or carer.

Not in the Forest of Dean?

If your practice is interested in using 'Just in Case' boxes please contact

Palliative Care Guidelines

Resource provided by GHFT to guidelines related to care in the last days of life and associated documents.

End of Life Care Resources

Please follow the resource link below to further information on Gloucestershire End of Life Care Resources including the order process, responsibilities and instructions.

End of Life Shared Care Record

Gloucestershire’s Shared Care Record for the expected last days of life launched 15 January 2015, and is available here.

The record is designed to support best possible clinical care at the end of life across the county. It can be used collaboratively by healthcare professionals in all care settings and should be shared with the patient and their carers.

Other useful resources: