COMMUNITY PALLIATIVE CARE CHART

Allergies and Adverse Drug Reactions – List the medicines or
Substances & the nature of the reaction (write NKDA if none)	
It is mandatory to complete this section	
Medicine/Substance	Reaction	
Sign 	Date	
Print Name	GMC/NMC number	
Allergy status unconfirmed.
Authority to administer ceases after 24 hours	Sign (NAME) GMC/NMC	Date	

First Name	Surname

Address:

NHS No:	DOB:

Consider the administration of a stat dose when starting a new syringe driver

SC SYRINGE DRIVER OVER 24 HOURS
Syringe driver	Dose	*Dose titration (community use)	
Drug (1)			
Drug (2)			
Drug (3)			
			
Diluent:		
Prescriber sig	Prescriber name (print)	Date	

Syringe driver	Dose	*Dose titration (community use)	
Drug (1)			
Drug (2)			
Drug (3)			
			
Diluent:		
Prescriber sig	Prescriber name (print)	Date	

Syringe driver	Dose	*Dose titration (community use)	
Drug (1)			
Drug (2)			
Drug (3)			
			
Diluent:		
Prescriber sig	Prescriber name (print)	Date	

Syringe driver	Dose	*Dose titration (community use)	
Drug (1)			
Drug (2)			
Drug (3)			
			
Diluent:		
Prescriber sig	Prescriber name (print)	Date	
*Dose titration (optional) - where medicines have been prescribed within a range of doses it is acceptable for Registered Nurses to titrate dosages according to patient response and symptom control, and to administer within the prescribed range. 
For information about syringe driver compatibility refer to current version Palliative Care Formulary

Allergies & Adverse Drug Reactions:	First Name:	Surname:	
	NHS No:	DOB:	

‘WHEN REQUIRED’ DRUGS
Please remember to issue a prescription of Water for injection to allow these drugs to be administered
Please note that Max dose in 24 hours should INCLUDE the syringe driver dose

Drug	ROUTE	Prescriber sig  (Print name)	Date	
MORPHINE	SC			
Dose		Frequency		
Indications   Pain/dyspnoea	Max dose in 24 hours -	

Drug	ROUTE	Prescriber sig  (Print name)	Date	
MIDAZOLAM (10mg/2ml)	SC			
Dose	2.5-10mg	Frequency		
Indications   Anxiety, dyspnoea, agitation, restlessness	Max dose in 24 hours – 80mg	
Indications   10mg to be given for seizure or large haemorrhage	

Drug	ROUTE	Prescriber sig   (Print name)	Date	
HYOSCINE BUTYLBROMIDE	SC			
Dose	20mg	Frequency		
Indication   Respiratory secretions	Max dose in 24 hours - 120mg	
Indication   Colic	Max dose in 24 hours - 300mg	

Drug	ROUTE	Prescriber sig   (Print name)	Date	
HALOPERIDOL	SC			
Dose	0.5-3mg	Frequency		
Indications   Nausea	Max dose in 24 hours - 5mg	
Indications   Agitation, hallucinations	Max dose in 24 hours – 5mg	

Drug	ROUTE	Prescriber sig  (Print name) 	Date	
	SC			
Dose		Frequency		
Indications	Max dose in 24 hours –	

Drug	ROUTE	Prescriber sig (Print name)	Date	
	SC			
Dose		Frequency		
Indications	Max dose in 24 hours –	

Drug	ROUTE	Prescriber sig  (Print name)  	Date	
	SC			
Dose		Frequency		
Indications	Max dose in 24 hours –	

Drug	ROUTE	Prescriber sig  (Print name) 	Date	
	SC			
Dose		Frequency		
Indications	Max dose in 24 hours –	

For advice please consult local policy or contact your local palliative care team
If advice is required Out of Hours please contact your local hospice or the on-call Palliative Care Consultant (via hospital switchboard) 

Author: FS Pharmacist	Date: March 2020	Approved: MedicinesOptomisation Group –March      Version: 3	Review date: March 2023