Clinical Guidelines

Resources for Healthcare Professionals

Below you'll find links to a selection of locally developed guidelines, links to national guidelines and other resources relating to palliative care. We hope these will be a useful addition to any local policies and guidelines in place in your area.

Remember - 24-hour specialist palliative care advice is available by calling our 24 hour clinical advice line on 0117 915 9430.

Hospice nurse with a patient

1. Local clinical guidelines

All these guidelines have had input from a number of local specialists in Palliative Medicine working in different settings. Some have had wider consultation and approval for use in a specific geographical area e.g. Bristol, North Somerset and South Gloucestershire (BNSSG) or Wessex. The source and (where applicable) geographical area is identified for each one.

  • Guidelines on the management of pain due to cancer in adults (BPCC). Includes advice on starting and changing opioids plus easy opioid conversion tables. (Updated 2017)
  • BNSSG Community anticipatory prescribing for end of life symptoms during the COVID-19 pandemic for patients with any diagnosis including COVID-19
    Developed by BNSSG Palliative Care consultants, trust and CCG pharmacists. Approved by Clinical Cabinet.
    This guidance contains a range of resources for anticipatory prescribing to facilitate good symptom control at the end of life. It takes into account the extraordinary circumstances of the COVID pandemic by suggesting non-injectable options for certain groups of patients. A decision aid flow diagram is available here. Prescribers need to be aware that there may be shortages of our usual injectable medications, consider providing only 5 doses of each drug for less complex patients. Consider anticipatory prescribing for any patient in their last 4 weeks of life. A new EMIS protocol will be distributed in late April to support the process. Secondary care have aligned their discharge medication to comply with this guidance. We will be updating this page as resources become available.

    1. Non complex patients
    Suitable for patients who are: opioid naïve who do not have severe symptoms and who are not already on a range of medicines for symptom control.
    Choose one option:
    A: Non injection pack: If a carer can administer medications: (adjust morphine dose if eGFR <30 or if very frail). Carer leaflet available here. These can be authorised for DNs to administer on the usual Community Palliaitve Care Drug Chart if needed.
    B: Injection pack: If no carer to administer medications (adjust opioid according to eGFR)
    Process: Either Prescribe on FP10, send to local or designated pharmacy and authorise on Community Palliative Care Drug Chart or use process for Just in Case Packs coming soon.

    2. Complex patients 
    Suitable for those with complex severe symptoms, OR already on opioids OR history of complex symptoms e.g. medication for more than one symptom, OR can’t tolerate standard medication OR symptoms not controlled on Pack A.
    Choose one option:
    C: Usual injectable guidance table: for most complex. Prescribe and authorise on Community Palliative Care Drug Chart as usual. For patients with COVID-19 also prescribe paracetamol 500mg suppositories for fever. Remember opioids can be used for breathlessness and cough. Consider whether this patient would be appropriate for informal carer administration of injectable medication
    D: Tailored non injections: If a carer can administer these and injections may not be possible due to shortages.
    Other resources for anticipatory prescribing and symptom control
  1. Flow diagram for anticipatory prescribing during the COVID pandemic
  2. Community palliative care prescribing table: usual injectable and syringe pump medication for symptom control (option C). (BPCC) 2015
  3. Pharmacies providing Enhanced Service for the Availability of Specialist Medicines and the medication they hold can be found here. Always telephone pharmacy to confirm stock and opening hours during the pandemic as subject to change.
  4. Anticipatory Prescribing Guidance Notes 2014 (to support option C)
  5. Informal carer administration of subcutaneous injectable medication
  6. RCGP/APM Guide: Community Palliative, End of Life and Bereavement Care in the COVID-19 pandemic. Useful general symptom control advice. Note BNSSG guidance is broadly in line, with this guide. Where there are differences they have been approved by the BNSSG working party.
  7. Anticipatory Prescribing: full standard operating procedure and guideline (BNSSG) 2015 (Detail for option C: usual guidance)

2. Local services for end of life care

3. Advance Care Planning, Resuscitation Decisions and ReSPECT (Recommended Summary Plan for Emergency Care and Treatment)

  • ReSPECT stands for Recommended Summary Plan for Emergency Care and Treatment. It is about creating a personalised recommendation for someone’s future clinical care in emergency situations where they are not able to make decisions or express their wishes.
    It will also record a Do Not Attempt Cardiopulmonary Resuscitation (DNAR) decision if one has been made. However, ReSPECT is about much wider care preferences and treatment plans and is equally applicable to patients for whom resuscitation is appropriate.
    Local implementation and procedure can be found at remedy pathway-ReSPECT
    National guidance can be found at ReSPECT-National Resuscitation Council

  • National Resuscitation Council guidelines: Decisions relating to cardiopulmonary resuscitation 

General ACP information

Advance decision to refuse treatment (ADRT)

ADRT forms provided with permission from 'Deciding Right and The Northern England Clinical Networks'

  1. Fillable form (to download and complete)
  2. Print form (for handwritten completion)

Lasting power of attorney (LPA)