Are non-injectable anticipatory medications a viable end-of-life intervention in the community? A systematic review and narrative synthesis

Background The anticipatory prescribing of injectable medications for symptom management at the end-of-life is an established practice in the UK. Transmucosal and inhaled routes of administration offer alternatives to injections, when patients are no longer able to take medications orally. Their evidence base in the community setting has not been established. Aim To systematically review and synthesise the published, peer-reviewed evidence regarding the clinical practice and effectiveness, including patients’, family caregivers’ and healthcare professionals’ views, of transmucosal and inhaled anticipatory medications for symptom management at the end-of-life in the community. Method Ten literature databases were searched from inception to February 2025, using terms for non-injectable anticipatory medications, or kits, combined with end-of-life terms. Two journals were hand-searched from 2015 to 2025. References and citations of included papers were searched. Gough’s Weight of Evidence Framework was used to appraise the included studies and inform the narrative synthesis. Results Fifteen papers were included, reporting the use of transmucosal routes, of which nine used a standardised medication kit. The limited evidence of clinical effectiveness, and the views of patients, family caregivers, and healthcare professionals, suggested that transmucosal medications were effective at relieving patients’ symptoms and enabling patients to die at home. Conclusion The evidence regarding transmucosal anticipatory medications in the community suggests that they are acceptable, clinically effective, and contribute to reducing unplanned hospital attendances, but is limited and should be treated with caution. Further research is needed to assess whether they offer viable alternatives to injectable anticipatory medications in the community.