Prescribing considerations at the end of life

GPs have a central role in decisions about prescribing medications to help control symptoms at the end of life.

Key points

  • Issues related to safe use of medicines in palliative care are important to consider. They include:
    • Monitoring for effectiveness and adverse effects
    • Minimising burden on patients
    • Safety of opioid use and disposal
    • Complexities of opioid prescribing
    • Polypharmacy
    • Deprescribing.
  • Be aware that some medications have a specific palliative care listing or require an authority prescription.
  • A palliative care listing allows larger quantities of medications to be prescribed, to reduce burden in terms of costs and need for repeat prescriptions.
  • Palliative care listings are 'authority required' - an initial authority is requested for a 4 month supply for palliative care patients. Subsequent prescriptions require confirmation that a palliative care service has been consulted.
  • For palliative care patients, it is best to use the palliative care listing and not the general benefits system if a drug is available in both lists.
  • For long-term opioids, using authority scripts is extremely helpful for the patient as standard scripts provide very small quantities.
  • The PBS website lists preparations which may be prescribed specifically for patients receiving palliative care:
  • Be aware of non-PBS medications that are sometimes recommended for palliative care patients.
    • Sometimes non-PBS medications may be essential, with no suitable PBS alternatives - discussion with the prescriber is helpful to clarify this. If non-PBS listed medications are required, a plan for how the patient can access them will be needed as well
    • The commonest are cyclizine (an antihistamine for nausea), and levomepromazine (also called methotrimeprazine - an antipsychotic for nausea and/or agitated delirium). They are obtainable via the Special Access Scheme
    • Sometimes a hospital pharmacy or palliative care service will take responsibility for ongoing supply and management of such medications.
  • 'Off-label' medications are often prescribed for palliative care patients.
    • These are medications prescribed for a different indication or route than the one for which they are approved by the TGA, for example:
      • Antipsychotics or antihistamines for nausea
      • Antidepressants or anticonvulsants for neuropathic pain
      • Administration of IV preparations by the subcutaneous route, and in combination.
  • Evidence for off-label use of these medications may be available, but has sometimes not been used by the drug company to obtain a listing for their medication.
  • Generally there is considerable clinical experience with the common off-label uses of medications in palliative care. Your local palliative care team can advise you on their own approach.

Useful Tip

In general, injectable medications that do not require dilution or a separate diluent can safely be given subcutaneously, with the exception of prochlorperazine and diazepam.

Last updated 24 August 2021