Prescribing

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:
• Access to medicines for palliative care on the PBS
• Browse by 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.