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Continuous subcutaneous infusion: is community anticipatory prescribing and administration safe?
  1. Séamus Coyle1,2,
  2. Rebecca Sinden3,
  3. Jade Wignall-Coyle4,
  4. Sinead Benson1,
  5. Paula Powell5 and
  6. Daniel Monnery1
  1. 1 Palliative Medicine, Clatterbridge Cancer Centre NHS Foundation Trust, Bebington, Wirral, UK
  2. 2 University of Liverpool, Liverpool Head and Neck Centre, Liverpool, UK
  3. 3 Medical School, University of Liverpool, Liverpool, Merseyside, UK
  4. 4 Community Specialist Palliative Care Team, Mersey Care NHS Foundation Trust, Liverpool, UK
  5. 5 Medical Director, Willowbrook Hospice, Prescot, UK
  1. Correspondence to Dr Séamus Coyle, Clatterbridge Cancer Centre NHS Foundation Trust, Bebington, Wirral, UK; s.coyle{at}


Objective The anticipatory prescribing of pro re nata medications and continuous subcutaneous infusion (CSCI) medication is essential for the timely management of symptomatic patients at the end of life. There is no evidence to support the safety or appropriateness of anticipatory CSCIs. In 2013, in response to safety concerns about end of life prescribing in the community, we designed an educational intervention to improve prescribing practices among non-specialist prescribers in this area.

Methods: how the study was performed We performed a safety-focussed retrospective cohort analysis of end of life community prescriptions of anticipatory CSCIs over a 12-month period, 5 years after creating clinical guidelines and embedding a multiprofessional rolling education programme. Medications prescribed and administered for symptom control at the end of life are compared between specialist and non-specialist prescribers in terms of their adherence to best practice guidance.

Results Medications prescribed were not universally administered and more commonly not administered without specialist input. Prescriptions of higher doses of opioids and benzodiazepines beyond those recommended by guidance were significantly greater within the cohort of patients receiving specialist oversight. The prescription of a dose range did not result in excessive dose escalation. For patients not receiving specialist palliative care, median morphine and midazolam doses did not escalate at all once a CSCI was commenced. All midazolam administrations were safe.

Conclusions The practice of anticipatory CSCI prescribing and administration can be safe in the community non-specialist setting when supported by clinical guidelines, specialist advice and ongoing multiprofessional education.

  • clinical decisions
  • drug administration
  • education and training
  • home care

Data availability statement

Data are available upon reasonable request. All participant data are deidentified.

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Data availability statement

Data are available upon reasonable request. All participant data are deidentified.

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  • Contributors All authors were involved in critical review of the manuscript and have seen and approved the final version. Specific contributions as follows; education intervention: PP; study design: SC; data acquisition: SC and RS; drafting the manuscript and revision of manuscript: SC, JW-C, DM, SB and PP.

  • Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

  • Competing interests None declared.

  • Provenance and peer review Not commissioned; externally peer reviewed.