Syringe Driver Commencement in Palliative Care :Comprehensive Triage Questionnaire

Syringe drivers play a vital role in palliative care, delivering continuous subcutaneous medication to manage distressing symptoms such as pain, nausea, breathlessness, and agitation. This essential tool supports effective symptom control, particularly in the community setting, where timely and accurate assessment is critical for addressing the complex needs of patients.

The Comprehensive Triage Questionnaire for syringe driver initiation has been specifically designed to streamline the evaluation process. By systematically addressing key factors—clinical urgency, logistical considerations, and patient-specific needs—this tool ensures that decisions are both patient-centered and resource-conscious.

Syringe Driver Triage Questionnaire

1. Patient Information

1. What is the patient’s name?

2. What is the patient’s age?

3. What is the patient’s primary diagnosis?

4. Where is the patient currently located?

Home Care home Hospice Other:

5. Who is the requesting district nurse?

Name:

Contact details:

2. Clinical Assessment

6. What symptoms is the patient experiencing?

7. Rate the severity of symptoms using a validated tool:

Mild Moderate Severe

8. What medications are currently prescribed?

9. Are the current medications effective?

Yes No (specify why):

10. Has there been a recent change in the patient’s condition?

Yes (describe): No

3. Syringe Driver Rationale

11. Why is a syringe driver being requested?

Inability to swallow Poor absorption of oral medications Symptom control

12. What symptoms will the syringe driver address?

Medication 1: Dose:

Medication 2: Dose:

Medication 3: Dose:

Medication 4: Dose:

14. How many stat doses of end-of-life medications have been administered in the past 24–48 hours?

14b. Are there any PRN medications available, and what are the instructions for their use?

Yes (specify): No

14c. Are drug charts, MAR charts, or equivalent documentation available?

Yes No

15. Does the patient have any known medication allergies?

Yes (specify): No

4. Patient and Family Considerations

16. Is the patient aware of their condition and prognosis?

Yes No

17. Does the family/carer understand the purpose of the syringe driver and how to manage it?

Yes No

5. Urgency Assessment

18. What is the urgency of the request?

Same day Within 24 hours Within 48 hours

6. Additional Information

19. Are the necessary equipment and medications available?

Yes No (specify):

20. Does the patient have kidney or hepatic failure / impaired renal function?

Yes No

21. Are palliative care specialist teams or agencies (e.g., St. David’s nurses) involved in the patient’s care?

Yes (specify): No

22. Is there a Do Not Attempt Resuscitation (DNAR) order in place?

Yes No

23. Is there any other relevant information from the district nurse’s assessment?

7. Monitoring and Follow-Up Plan

24. Who will monitor the patient’s response to the syringe driver?

District nurse (frequency): GP (frequency): Specialist palliative care team

25. Is there a plan in place to manage potential adverse effects (e.g., sedation, respiratory depression)?

Yes No

8. Cultural and Religious Considerations

26. Are there any cultural or religious considerations relevant to the patient’s care?

Yes (specify): No

Advisory for Clinicians

When managing patients on syringe drivers, it is essential to maintain clear and comprehensive documentation to ensure continuity of care. Consider the following guidelines:

By adhering to these principles, clinicians can enhance patient safety, ensure effective symptom control, and facilitate smooth transitions of care.

[1] https://aci.health.nsw.gov.au/palliative-care/guideline/implementation/specialist-community-triage-guideline

[4] https://www.palliativecarescotland.org.uk/content/publications/09.-Community-referrals.pdf