1. Aims: What matters to the individual about their condition(s)?
Review diagnoses and consider:
- Therapeutic objectives of drug therapy
- Management of existing health problems
- Prevention of future health issues, including lifestyle advice
Ask person to complete PROMs (Questions to answer before medicines review) before their review
Person specific issues to address
- Pain control
- Control of other symptoms such as nausea, constipation, sore mouth, breathlessness and fatigue
- Struggling to swallow medications
- Diabetic control
- Desire for cigarettes
2. Need: Identify essential drug therapy
Identify essential drugs (not to be stopped without specialist advice)
- Drugs that have essential replacement functions (e.g. levothyroxine)
- Drugs to prevent rapid symptomatic decline (e.g. drugs for Parkinson’s disease, heart failure)
Person specific issues to address
- Insulin- should not be stopped in those known to have type 1 diabetes
- Analgesics (fentanyl, morphine, paracetamol, ibuprofen)- assess effectiveness and tolerability of each analgesic, check requirement of breakthrough doses of morphine
- Metoclopramide- switch to antiemetic with longer half-life that can be given once daily or administer via Continuous Subcutaneous Infusion (CSCI)
- Omeprazole: gastric protection whilst taking non-steroidal anti-inflammatory drug (NSAID); indicated for oesophagitis.
3. Does the individual take unnecessary drug therapy?
Identify and review the continued need for drugs
- what is medication for?
- with temporary indications
- with higher than usual maintenance doses
- with limited benefit/evidence for use
- with limited benefit in the person under review (see Drug efficacy & applicability (NNT) table)
Person specific issues to address
- Antihypertensive - Stop as hypotensive. Low BP is common near the end of life
- NSAID - indicated for bone pain but patient at risk of gastrointestinal complications, especially if unable to take gastric protectant. Assess risk versus benefit
- Antidepressant - Stop at a pace he can manage. Fluoxetine has long half-life. Benzodiazepine (e.g. midazolam) may be needed to counteract anxiety/ discontinuation/withdrawal symptoms
- Oral care - be aware of fluconazole drug interactions but of less relevance near end of life
- Laxative-stop. Likely to struggle to swallow volume of macrogol laxative in the last days of life due to poor fluid intake. Rectal laxatives can be considered if needed for comfort measures
4. Effectiveness: Are therapeutic objectives being achieved?
Identify the need for adding/intensifying drug therapy to achieve therapeutic objectives
- to achieve symptom control
- to achieve biochemical/clinical targets
- to prevent disease progression/exacerbation
- is there a more appropriate medication to achieve goals?
Person specific issues to address
- Prescribe as required medicines in anticipation of need for distressing symptoms (analgesic, antiemetic, anxiolytic sedative, anti-secretory). Prescribe subcutaneous (SC) route in addition to any existing oral (PO) route.
- Consider likelihood of catastrophic haemorrhage; Prescribe anxiolytic sedative by the intramuscular (IM) route in anticipation of need (e.g. midazolam 5mg to 10mg)
- Switch to a simpler insulin regimen aiming to prevent symptomatic diabetic ketoacidosis (e.g. once daily insulin glargine). Reduce the dose as appetite decreases, seeking advice from diabetic team on a case-by-case basis. Review dose daily
- If unable to swallow, switch oral medication to subcutaneous administration via a syringe pump (CSCI) if possible. Alternative medications may need to be considered
- Do not switch opioid patch to alternative opioid/route in a dying patient; continue the fentanyl patch and administer any additional opioid required via CSCI.
- Ensure breakthrough opioid dose is calculated as 1/6th to 1/10th of total oral morphine daily equivalent. Contact specialist palliative care team for advice if uncertain.
- Consider benefit of nicotine replacement therapy (NRT) if unable to smoke to avoid effects of nicotine withdrawal
- Assess need for oxygen therapy if oxygen saturations <88-92%. Manage respiratory distress first line with opioids / benzodiazepines. Oxygen may help alleviate refractory symptoms, or lessen hypoxic related delirium
5. Safety: Does the individual have or is at risk of ADR/ side effects? Does the patient know what to do if they’re ill?
Identify individual safety risks by checking for
Identify adverse drug effects by checking for
- specific symptoms/laboratory markers (e.g. hypokalaemia)
- cumulative adverse drug effects (see ADR table)
- drugs used to treat side effects caused by other drugs
Medication Sick Day guidance
- Ensure discussion and clear information on which medicines to withhold at times of dehydrating illness
Person specific issues to address
- NSAID - manage the risks and benefits of continuing treatment, particularly if gastric protection cannot be administered
- Antidepressant - increased risk of bleeding with SSRI/SSNRI
- PPI - Switch capsules to orodispersible tablets. Alternatively, open capsules and mix the contents with water, fruit juice or sprinkle on soft food
- Fluconazole - may increase the plasma concentration of all drugs metabolized by CYP3A4 (e.g. fentanyl, midazolam). Review requirement
- Insulin - preventing distressing symptoms of diabetes is the goal towards the end of life; a range of 6-20mmol/l is generally accepted, although 6-15mmol/l may to necessary to prevent distressing thirst, particularly in younger patients
- Monitor for signs of gastrointestinal (GI) toxicity (bleeding)
6. Sustainability: Is drug therapy cost-effective and environmentally sustainable?
Identify unnecessarily costly drug therapy by
- considering more cost-effective alternatives, formulary choices, safety, convenience
Consider the environmental impact of
- Inhaler use
- Single use plastics
- Medicines waste
- Water pollution
Person specific issues to address
- Prescribe the advised number of ampoules for anticipatory ‘Just in Case’ medicines
- Utilise the person’s own medication supply wherever possible
- Advised to dispose of medicines no longer required through the community pharmacy
7. Person-centredness: Is the person willing and able to take drug therapy as intended?
Does the person understand the outcomes of the review?
Ensure drug therapy changes are tailored to individual’s preferences. Consider
- is the medication in a form they can take?
- is the dosing schedule convenient?
- what assistance is needed?
- are they able to take medicines as intended?
Agree and communicate plan
- discuss and agree with the individual/carer/welfare proxy therapeutic objectives and treatment priorities
- include lifestyle and holistic management goals
- inform relevant health and social care providers of changes in treatments across the transitions of care
Ask person to complete PROMs (Questions to answer after medicines review) after their review
Agreed plan
- Stop: Antidepressant, antihypertensive, fluconazole, laxative, zopiclone, paracetamol (tablet burden)
- Switch: Symptom focused medications to liquid/ orodispersible formulations or oral to CSCI/SC (SC appropriate for antiemetic and opioid titration).
- Consider: NSAID can be continued until end of life if helpful for symptom control and benefits are considered to outweigh risks. Seek SPC advice if parenteral NSAID is required
- Simplify: Ensure patient and /or family/POA (depending on capacity) understand and agree with goals of care. Communicate that comfort is paramount as patient is nearing end of life
Polypharmacy guidance: Appropriate prescribing making medicines safe, effective and sustainable 2026-2029
