When a patient enters the last days of life, rapid access to specific medicines can make the difference between a comfortable death and an avoidable crisis. Community pharmacies are the primary source of anticipatory medicines for patients dying at home — yet national audits consistently show that stock availability of key palliative drugs remains patchy, particularly outside business hours.

Anticipatory prescribing: the "just in case" approach

Anticipatory prescribing is the practice of providing medicines in advance for symptoms that are likely to develop as a patient approaches end of life. The aim is to ensure that when pain, nausea, agitation or respiratory secretions develop — often suddenly and outside normal hours — the medicines are already in the home and a healthcare professional can administer them without delay.

The most commonly prescribed anticipatory medicines are:

These medicines are typically prescribed as a "just in case" box or anticipatory medicines kit, issued by the GP or palliative care team and dispensed by the community pharmacy.

The stock availability challenge

A 2019 survey by the Royal Pharmaceutical Society found that 42% of community pharmacies reported difficulty sourcing at least one palliative care medicine in the previous month. The most frequently cited difficulties involved injectable formulations of midazolam, levomepromazine and alfentanil — all of which are controlled drugs or have limited shelf life.

The problem is structural rather than negligent. Community pharmacies operate on a commercial dispensing model: they stock medicines in proportion to demand. A pharmacy that dispenses one anticipatory medicines kit per quarter cannot economically hold a full range of injectable palliative medicines in stock at all times — the risk of expiry and wastage is significant.

Palliative care pharmacy networks

To address stock availability, many areas in England have established palliative care pharmacy networks. These typically involve:

• Nominated pharmacies: a small number of pharmacies in each area that commit to holding a full range of anticipatory medicines at all times, in exchange for a local enhanced service payment
• Out-of-hours rotas: agreements between pharmacies to ensure at least one is open or on-call to supply palliative medicines outside normal hours
• Stock-holding lists: local palliative care teams publish lists of which pharmacies currently hold which medicines, accessible to district nurses and GPs

The effectiveness of these networks varies considerably by area. Urban centres with multiple pharmacies typically have better coverage than rural areas, where the nearest pharmacy holding injectable midazolam may be 30 miles away.

Controlled drug considerations

Several key palliative care medicines are Schedule 2 controlled drugs (morphine, alfentanil, midazolam). This creates additional practical challenges:

• Prescription validity: CD prescriptions must be dispensed within 28 days of the date on the prescription. Anticipatory prescriptions issued too early may expire before the medicines are needed
• Storage requirements: Schedule 2 CDs must be stored in a locked cabinet meeting specific Home Office specifications
• Record-keeping: every supply must be recorded in the CD register, with the patient's name and address, the prescriber, and the quantity supplied
• Destruction of unused medicines: when a patient dies, unused CDs must be destroyed in accordance with regulations — typically by a pharmacist or authorised witness

Pharmacists handling palliative care CDs should also be aware that injectable formulations of morphine and midazolam are frequently requested urgently — sometimes by distressed family members or district nurses outside normal hours. Having a clear process for urgent CD supply, including contact details for on-call pharmacies, is essential.

The pharmacist's clinical contribution

Beyond supply, community pharmacists can contribute to palliative care in several ways:

• Medication review: patients approaching end of life are often on complex regimens that include medicines no longer appropriate. A pharmacist-led review can identify medicines to stop (linking to the deprescribing role described in current NICE guidance)
• Formulation advice: when a patient can no longer swallow, the pharmacist can advise on alternative formulations — liquids, patches, suppositories, or subcutaneous routes
• Syringe driver compatibility: pharmacists can advise district nurses on which drugs can be mixed in a syringe driver and which require separate administration
• Family support: dispensing an anticipatory medicines kit is an opportunity to explain to the family what each medicine is for, how it will be given, and what to expect

Where to explore further

Pharmacists interested in palliative care roles can search PharmSee's job listings for hospice, palliative and end-of-life pharmacy positions. The pharmacy search tool can help identify local pharmacies by area, and salary data provides context on how palliative care specialist pharmacist roles compare to generalist positions.

Caveats

Anticipatory prescribing regimens and local formulary choices vary between areas and palliative care teams. The medicines and doses listed above are based on commonly used national guidelines and should not be taken as prescriptive. The RPS stock availability figure is from a 2019 survey and may not reflect current conditions. Controlled drug regulations are summarised here for general reference; pharmacists should consult the latest Home Office and GPhC guidance for specific requirements.

Sources

• NICE NG31: Care of Dying Adults in the Last Days of Life (2015, updated 2017)
• Royal Pharmaceutical Society: Palliative Care Pharmacy Stocklist Survey (2019)
• NHS England: Palliative and End of Life Care — Statutory Guidance
• GPhC: Guidance on Controlled Drugs
• PharmSee vacancy database, 1,715 active roles as at 15 April 2026