Syringe Drivers in Palliative Care: A Practical Guide for Nurses

In the last days of life, many patients can no longer swallow tablets. Some have persistent nausea, pain or agitation that needs round-the-clock relief. A syringe driver (also called a syringe pump or continuous subcutaneous infusion, CSCI) delivers medicines steadily under the skin over 24 hours, so the patient doesn’t need repeated injections. It is one of the most important tools in palliative care, whether in a hospice, hospital ward or a patient’s own home.

When is a syringe driver used?

• The patient can’t swallow, is too weak or unconscious
• Persistent nausea and vomiting prevent oral medicines working
• Bowel obstruction or poor absorption from the gut
• Symptoms need steady control rather than peaks and troughs

A syringe driver doesn’t mean a patient is about to die. Some patients use one for weeks, for example with bowel obstruction from cancer. It also doesn’t hasten death when used correctly; it treats symptoms.

Commonly used devices include the McKinley T34 and BD BodyGuard T, which have safety features such as lock boxes and alarms. Older devices without these features have been withdrawn in many countries after errors.

Medicines commonly used

Medicines and doses are always prescribed by a doctor or non-medical prescriber, often with specialist palliative care input. Common examples include:

• Pain and breathlessness: opioids such as morphine, diamorphine or oxycodone; alfentanil may be used in kidney failure.
• Nausea and vomiting: levomepromazine, haloperidol, cyclizine or metoclopramide.
• Agitation and distress: midazolam; levomepromazine or haloperidol for delirium.
• Respiratory secretions (“death rattle”): hyoscine butylbromide or glycopyrronium.

Several medicines are often mixed in one syringe. Not all combinations are compatible, so prescribers and nurses should check compatibility using a recognised palliative care reference. Water for injection is the usual diluent for most mixtures; some medicines need sodium chloride 0.9%.

In many low-resource settings, morphine may be the only strong opioid available. The WHO lists oral and injectable morphine as essential medicines, and nurses play a key role in advocating for access to pain relief.

Setting up a syringe driver: key steps

Always follow your organisation’s policy and complete local training before setting one up. The general process is:

1. Check the prescription: drugs, doses, diluent, total volume and duration (usually 24 hours). Check for allergies and previous doses.
2. Explain to the patient and family what the syringe driver is for, that it won’t make them sleep unless that’s the aim, and what the alarm sounds mean.
3. Prepare the syringe using aseptic technique. Use a Luer-lock syringe of the size your device requires (many policies use 20 mL or 30 mL syringes). Label it clearly with patient name, drugs, doses, diluent, date and time, and your signature.
4. Prime the line before starting. Most devices prompt you to prime; account for this volume as per policy.
5. Choose the site. Suitable sites include the upper chest, upper arms, abdomen, and the back between the shoulder blades (useful for restless or confused patients). Avoid oedematous areas, bony prominences, broken skin, areas recently irradiated and sites near tumours.
6. Insert a subcutaneous cannula (a small non-metal cannula is preferred) and secure with a transparent dressing so the site can be seen.
7. Load and start the pump, confirming the rate (mL per hour) on the screen matches the calculated volume over 24 hours.
8. Lock the device in its box if your policy requires it.
9. Document the start time, contents, site, rate and the volume in the syringe.

Monitoring and checks

Check the syringe driver regularly, often at least four-hourly in hospital, and at every visit in the community:

• Is it running? Check the light or screen and listen for alarms.
• Volume infused and remaining: compare with what you’d expect at that time. If it’s running faster or slower than expected, investigate.
• The line: any kinks, leaks or disconnections?
• The syringe contents: look for cloudiness, crystals or colour change, which can mean drugs aren’t compatible. If seen, stop the infusion and seek advice.
• The site: redness, swelling, hardness, pain or leakage. Re-site the cannula if any of these occur. Many policies re-site every 72 hours or sooner.
• The patient: are symptoms controlled? Any signs of drowsiness, breathing changes or toxicity?

Record each check on the syringe driver monitoring chart.

Breakthrough symptoms

A syringe driver provides background control. Patients also need “as required” (PRN) subcutaneous doses prescribed for breakthrough pain, nausea, agitation and secretions. If a patient needs several PRN doses in 24 hours, tell the prescriber; the syringe driver dose may need adjusting.

Common problems

• Site reactions: some drugs (such as cyclizine and levomepromazine) irritate tissue. Diluting to a larger volume or re-siting more often may help.
• Running too fast or too slow: check the device, battery and line, and that the syringe is correctly fitted. Report and document any discrepancy.
• Occlusion alarm: look for kinks, a blocked cannula or a closed clamp.
• Battery failure: check and replace batteries when starting each new syringe.

Communication with families

Families may fear that the syringe driver is “what killed” their relative, especially if death comes soon after it starts. Explain gently that it’s used because the person is too unwell to swallow, and that its purpose is comfort. Encourage them to tell you if they notice the person seems distressed. Being honest and kind at this stage helps families grieve without guilt or suspicion.

Key points

• Syringe drivers deliver continuous subcutaneous medicines over 24 hours for symptom control.
• Check prescriptions, compatibility and calculations carefully.
• Choose and monitor sites carefully; re-site at the first sign of problems.
• Check the device, volume, line and patient regularly and document each check.
• Make sure breakthrough PRN doses are prescribed.
• Explain the purpose clearly to patients and families.

References

• NICE NG31: Care of dying adults in the last days of life
• WHO fact sheet: Palliative care
• NHS England: End of life care resources