Anticipatory Prescription Stat Doses
Version No
5.0
Version Date
13.1.15
Review Date
13.1.17
ALLERGIES
SURNAME
“JUST IN CASE”
NHS No: _ _ _ / _ _ _ / _ _ _ _
FORENAME
D.O.B.
ANTICIPATORY
PRESCRIPTION
SHEET
This form must be completed by a Clinician who is prescribing Diamorphine/Morphine/Haloperidol/Hyoscine Butylbromide/Midazolam
If drug dosages adjusted in syringe driver, breakthrough analgesia doses may need to be revised. Please refer to Symptom Management Guidelines
Palliative Care
PRESCRIBER SIGNATURE/
DATE/TIME
DRUG
DOSE
FREQUENCY
DESIGNATION
th of total 24-hour opiate requirement
As
required
(PRN)
doses
for
breakthrough
pain
should
be
1/6
Diamorphine
s/c
expressed as the equivalent in diamorphine. To calculate the 24 hour requirements add together all
opioids including syringe driver, transdermal patch, subcutaneous and oral doses expressed as their
equivalent in diamorphine then calculate 1/6th. PRN doses can be given up to ½ hourly for
uncontrolled pain.
Haloperidol
1.5mg to
2.5mg s/c
Up to hourly for nausea/agitation (maximum including syringe driver dose 15mg in 24hours).
Hyoscine
butylbromide
20mg s/c
Up to hourly for respiratory secretions (maximum including syringe driver dose 80mg in 24hours (Palliative Care Formulary))
Midazolam
2.5mg
One hourly for maximum 3 doses then seek medical advice (for anxiety).
Water
10ml
To re-constitute diamorphine and/or to make syringe driver up to final volume
Patients requiring more than 3 as required doses within 4 hours seek medical advice.