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16.15 Just in case bags
In order to minimise distress to the patient and their families it is necessary to anticipate the need for medication. One way this can be achieved is via the supply of Just in Case Boxes/Bags (JICB). The decision to initiate the use of any of the drugs in the Just in Case bag must be made by a doctor caring for the patient.
Once the patient has a syringe driver in situ, there is no longer a need for a Just In Case bags and “as required” subcutaneous medication should be prescribed on the relevant syringe driver prescription form.
Just in Case bags with standard medication have been in use since 2011 and have proved to be a useful addition to the care of patients who are approaching the end of life. The medications contained within the Just in Case Bags are intended to be used when there is a sudden or unexpected deterioration in the patient's health and must be followed with review of the medication within 24 hours.
The list of drugs to be included in the 'Just in Case' bags is advisory only; it is still important that you tailor your prescription to the needs of your patient e.g. you may want to prescribe a different opiate for a patient in renal failure (see below).
Possible exceptions to the supply of a Just in Case Bag:
- Patients where there is a history or suspicion of drug misuse among carers or visitors to the house
- Patients who are themselves unwilling to participate, or with carers who are unwilling to participate (although nurses and doctors may be able to provide re-assurance in most cases).
Standard Just In Case Bags for patients without COVID-19
2 x ampoules of morphine sulfate 10mg/1ml for pain or breathlessness at a dose of 2.5 to 5mg when required s/c*
3 x ampoules of midazolam 10mg/2mL for terminal restlessness, anxiety and agitation at a dose of 2.5 to 5mg when required s/c.
3 x ampoules of hyoscine hydrobromide 400 micrograms/mL for respiratory tract secretions or rattle which is distressing the patient at a dose of 400 micrograms when required s/c.
2 x ampoules of levomepromazine 25mg/mL for nausea and vomiting at a dose of 6.25mg when required s/c
2 x ampoules of haloperidol 5mg/mL for hallucinations and agitations at a dose of 1.5mg – 3mg when required s/c**
*Consider whether patient opiate naïve or if there is a requirement for high dose for breakthrough pain if on regular opiate.
** Agitation and restlessness - check that the patient is not in urinary retention or extremely constipated.
There is an increasing focus on the needs of patients who have End-Stage Kidney disease and who are either withdrawing from dialysis or are opting to have conservative management only.
These patients are probably best served by having a different collection of drugs in their Just in Case bag.
Nausea/vomiting
- 2 x haloperidol sc injection 0.5-1mg, 5mg/mL, 1mL ampoules
Hallucinations
- 2 x haloperidol sc injection 0.5-1mg, 5mg/mL, 1mL ampoules
Rattly Secretions
- 3 x glycopyrronium sc injection 200 micrograms, 200 micrograms/mL, 1mL ampoules
- Consider 3 x hyoscine butylbromide 20mg if glycopyrronium is unavailable, 20mg/mL, 1mL ampoules
Agitation
- 3 x midazolam 2.5mg - 5mg sc injection, 5mg/mL, 2mL ampoules
Breathlessness
- 3 x midazolam 2.5- 5mg sc injection, 5mg/mL, 2mL ampoules
See below for advice on opioids in breathlessness
Prescribing opioids for just in case bags in renal failure
Pain and Breathlessness
These prescribing issues are complex: your local palliative care team can help decide on the most appropriate opioids to use for each individual patient.
Standard opioids and their breakdown products (e.g. morphine) may accumulate over time and can cause significant toxicity with confusion, drowsiness and jerks.
Treatment depends on what the patient's background analgesia is. Please ring your local palliative care team for advice.
If opioid naïve, consider issuing:
- 5 x fentanyl 50 micrograms/mL 2mL ampoules. For a dose of 25 – 50 micrograms s/c when required, or
- 3 x oxycodone 10mg/mL 1mL ampoules. For a dose of 1.25 – 2.5mg s/c when required
Fentanyl and alfentanil are not renally excreted and so do not accumulate in renal failure. Because of their short half-life, they may be better in a syringe driver than prn.
Oxycodone SC 1.25-2.5mg is a good alternative as a when required for use at home as has a longer half-life. It seems to be better tolerated in patients with end-stage renal disease than morphine.
Again these decisions are complex and it is probably advisable to discuss such cases with specialist palliative care or renal teams.
NB: If a patient in renal failure is in pain, distressed and needs analgesia in an emergency, very small when required doses of morphine sulfate SC (e.g. 1.25 – 2.5mg) can be used and titrated to effect.
