This page is written for hospice agencies, hospice and home-health nurses, and palliative prescribers. It describes the preparations Bayview Pharmacy compounds for end-of-life symptom management, why several of them cannot be met with commercially available products, and the regulatory constraints that govern how they are ordered.
Every item described here is prepared only for an identified individual patient on a valid prescription. Nothing on this page is a recommendation to use any drug, route, or dose for any patient. Dosing figures are reported as they appear in the palliative care literature; selection, initiation, titration, and monitoring remain the prescriber's responsibility. Bayview compounds this as part of our hospice and palliative care compounding line.
Why concentrated preservative-free preparations are compounded
Subcutaneous tissue absorbs roughly up to 3 mL per hour. That volume ceiling is the reason concentrated opioid infusions exist. Commercial preservative-free opioid injection is generally capped at about 1 to 10 mg/mL, which cannot deliver opioid-tolerant hourly doses within that ceiling and forces impractically frequent cassette changes in the home. A patient whose order calls for 60 mg per hour of hydromorphone cannot receive it subcutaneously at a commercial 10 mg/mL concentration.
Preservative-free matters because benzyl alcohol and similar preservatives cause local tissue irritation at continuous subcutaneous infusion sites and accumulate as infused volume rises. Cassette size is selected as a function of the ordered rate multiplied by the desired interval between nurse visits, which is why the same concentration is stocked in several volumes. Persistent shortages of morphine and hydromorphone injection, both of which have appeared on the FDA and ASHP shortage lists, are an additional documented driver of compounding demand.
This explains why particular concentrations are compounded. It is not a statement that a compounded preparation is superior to, or interchangeable with, an available commercial product. Related hospice and palliative care preparations include Hydromorphone Infusion (Preservative-Free) and Morphine Infusion (Preservative-Free). The full list is in our compounded medications catalog.
Continuous subcutaneous infusion in the home
Continuous subcutaneous infusion (CSCI) is the usual parenteral route in home hospice when the oral route fails, dysphagia, obtundation, intractable vomiting, or bowel obstruction, and intravenous access is absent or burdensome to maintain at home. Morphine, hydromorphone, fentanyl, and sufentanil are all described as suitable for subcutaneous administration.
As described in the palliative care literature, a 25- or 27-gauge butterfly is placed in the upper arm, shoulder, abdomen, or thigh, avoiding the chest wall, and may remain in place up to about a week unless a local reaction develops. Sites are rotated for redness, induration, or leakage, and edematous or irradiated tissue is avoided. Evidence for intravenous-to-subcutaneous conversion is weak; many practitioners use a 1:1 ratio. Site care, gauge, and dwell time are nursing and prescriber decisions.
Formulations we prepare for hospice
The table below maps the catalog by symptom and preparation. Detail pages exist for the two highest-volume opioid infusions; the remaining entries are summarized in the sections that follow.
| Symptom or indication | Preparation | Notes |
|---|---|---|
| Pain or dyspnea, opioid-tolerant, subcutaneous volume-limited | Hydromorphone HCl preservative-free infusion, 5, 20, and 30 mg/mL | Schedule II. See the hydromorphone infusion page |
| Pain or dyspnea | Morphine sulfate preservative-free infusion, 5 and 20 mg/mL | Schedule II. See the morphine infusion page |
| Pain where renal impairment complicates opioid selection | Fentanyl citrate 50 mcg/mL and fentanyl 200 mcg/mL, preservative-free | Schedule II. No clinically significant active metabolites |
| Refractory terminal agitation, seizures, proportional palliative sedation | Midazolam 5 mg/mL infusion, 25, 50, and 100 mL | Schedule IV |
| Sedation or agitation where suppression of respiratory drive is a concern | Dexmedetomidine 40 mcg/mL infusion, 50 to 200 mL | Emerging and investigational in this setting. See below |
| Refractory or neuropathic pain, central sensitization, opioid tolerance | Ketamine 5 and 20 mg/mL infusion | Schedule III. Evidence is mixed. See below |
| Breakthrough pain, dyspnea, or anxiety when swallowing fails | Morphine oral concentrate 20 mg/mL; lorazepam oral concentrate 2 mg/mL | Commercially available FDA-approved products. See the restriction below |
| Terminal delirium; nausea of chemical or metabolic origin | Haloperidol; ABH-type oral or sublingual prefilled syringes (lorazepam 0.5 mg, diphenhydramine 12.5 mg, haloperidol 0.5 mg per mL) | Prefilled syringe is a convenience and adherence formulation |
| Airway secretions at the end of life | Atropine 1% ophthalmic solution given sublingually; glycopyrrolate | Sublingual use of an ophthalmic product is an off-label route. See below |
| Prescriber-requested topical preparation | Lorazepam 1 mg/mL topical gel, 1 mL syringe | Transdermal absorption is not supported by the available data. See below |
This table lists what Bayview compounds on prescription. It is not a treatment algorithm and does not indicate that any listed preparation is appropriate for a particular patient.
Midazolam
Midazolam is a short-acting benzodiazepine acting as a positive allosteric modulator at the GABA-A receptor. In hospice it is used for refractory terminal agitation, for seizures, and for proportional palliative sedation, and it is the most studied agent for palliative sedation in the home setting. Reported experience describes sedation achieved in about 97 percent of patients starting at 1 mg per hour, usual total daily parenteral doses under 100 mg, an average duration of sedation before death of roughly three days, and monitoring to a RASS target of approximately −1 to −4. These figures are reported from the literature for prescriber reference only; the prescriber sets the starting rate, titration, and sedation target.
Dexmedetomidine
Dexmedetomidine is a selective alpha-2 adrenergic agonist that acts at the locus coeruleus to produce what is described as cooperative sedation, with minimal suppression of respiratory drive compared with benzodiazepines and opioids. Bradycardia and hypotension are dose-limiting and require monitoring. Bayview compounds a 40 mcg/mL infusion in 50 to 200 mL volumes on prescriber request; no claim of efficacy in palliative care is made or implied.
Ketamine
Ketamine is an NMDA-receptor antagonist used in palliative care to target central sensitization, opioid tolerance, and neuropathic pain. Subanesthetic infusion dosing reported in the literature is 0.1 to 0.2 mg/kg/hr titrated by about 0.1 mg/kg/hr daily to a commonly cited maximum of 1 mg/kg/hr, or fixed dosing of 5 to 10 mg/hr with an upper range of 40 to 50 mg/hr, typically over 3 to 5 days, by either the intravenous or the subcutaneous route.
Fentanyl
Fentanyl is a highly lipophilic mu-opioid agonist with rapid onset, short duration, and no clinically significant active metabolites, which is why it is commonly selected as the infusion opioid when renal impairment complicates opioid choice. Bayview compounds fentanyl citrate 50 mcg/mL and fentanyl 200 mcg/mL preservative-free infusions. The 200 mcg/mL strength exists to fit high hourly dose requirements into the subcutaneous volume limits described above; it is not intended for any other purpose and is dispensed only on a patient-specific Schedule II prescription.
Oral concentrates and comfort-kit preparations
When swallowing fails, small buccal or sublingual-adjacent volumes of 0.25 to 0.5 mL are the backbone of home symptom management. Morphine oral concentrate 20 mg/mL and lorazepam oral concentrate 2 mg/mL are the two most commonly requested. Haloperidol is a D2 antagonist used first-line for terminal delirium and agitation and for nausea of chemical or metabolic origin such as uremia or opioid-induced nausea; an ABH-type combination of lorazepam, diphenhydramine, and haloperidol supplied as an oral or sublingual prefilled syringe is a defensible convenience and adherence formulation.
Airway secretions at the end of life
Atropine 1% ophthalmic solution given sublingually is described in the palliative literature at 1 drop every 4 hours as needed, with an onset of about 30 minutes and a duration of roughly 2 hours. Glycopyrrolate is described at 0.5 to 1 mg orally three times daily as needed, or 0.2 to 0.4 mg intravenously or subcutaneously every 4 hours as needed.
Lorazepam topical gel
No efficacy or absorption claim is published for this preparation. It is compounded only because a prescriber has requested it for an identified patient.
Palliative sedation
Palliative sedation is sedation used to relieve severe refractory physical distress such as pain, delirium, or dyspnea. It should not be prescribed with the intent to hasten death. It follows a proportionality principle: the least sedation needed to control the target symptom. Interdisciplinary review that includes pharmacy and spiritual care is recommended before initiation, together with explicit informed consent addressing whether sedation is intended to be intermittent or continuous until death.
Prospective multicenter data indicate that palliative sedation does not hasten death. It is categorically distinct from physician-assisted death by intent, by dose proportionality, and by reversibility. Bayview's role is limited to compounding on a valid patient-specific prescription; the clinical and ethical decision belongs to the care team.
Safety considerations
Respiratory depression is the principal opioid risk. Opioids correctly titrated to symptom relief do not cause respiratory depression; the risk lies in non-proportional dose escalation, in opioid-naive patients, and in benzodiazepine and opioid co-administration. Midazolam combined with an opioid infusion is the highest-risk combination in this catalog and warrants correspondingly close monitoring.
Equianalgesic conversion is the most common source of serious error. Incomplete cross-tolerance is generally handled with a 25 to 50 percent dose reduction when rotating opioids, and published conversion ratios are approximations rather than precise equivalences.
The common claim that hydromorphone is safe in renal failure is overstated. Morphine's glucuronide metabolites (M3G and M6G) accumulate in renal failure and may cause neurotoxicity, and hydromorphone follows a similar pattern through its own glucuronide metabolite. Reported guidance is a dose reduction of about 25 percent at a creatinine clearance of 10 to 50 mL/min and about 50 percent below 10 mL/min. Fentanyl and methadone have no active metabolites. Opioid neurotoxicity presents as myoclonus, hyperalgesia, and agitated delirium rather than simply as sedation.
These points summarize published clinical literature for prescriber reference. They are not dosing recommendations, and they do not describe any compounded preparation as safe.
USP <797> and beyond-use dating
The 2023 revision of USP General Chapter <797>, official November 1, 2023, replaced the previous low-, medium-, and high-risk model with Category 1, Category 2, and Category 3 compounded sterile preparations. You can read how we handle sterile compounding. Category 1 preparations are compounded in a primary engineering control within an unclassified segregated compounding area and carry short beyond-use dates. Category 2 requires a cleanroom suite, with beyond-use dates assigned per the chapter's Table 13. Category 3 permits longer beyond-use dates per Table 14 but requires sterility testing, extended environmental monitoring, and additional quality assurance.
The practical consequence for hospice ordering is that the assigned beyond-use date, rather than the chemical stability of the molecule, usually governs how long a cassette may be used. Beyond-use dates are assigned according to the USP <797> category and the testing performed for that preparation, and are printed on the label. Confirm the dating on the label of the specific preparation you receive.
Regulatory status and how orders are handled
Compounded preparations are not FDA-approved, and FDA does not verify their safety, effectiveness, or quality before marketing. Compounding under Section 503A must be for an identified individual patient based on a valid prescription. FDA's June 2016 503A guidance permits anticipatory compounding in limited quantities only where there is a documented history of valid prescription orders within an established pharmacist-patient-prescriber relationship.
Controlled substance scheduling for this catalog: hydromorphone, morphine, and fentanyl are Schedule II; ketamine is Schedule III; midazolam and lorazepam are Schedule IV. Under 21 CFR 1306.11, a Schedule II prescription must be written and signed. A facsimile prescription serves as the original written prescription, with no follow-up hard copy required, for (a) a Schedule II narcotic compounded for direct parenteral administration by intravenous, intramuscular, subcutaneous, or intraspinal infusion, (b) a resident of a long-term care facility, and (c) a patient enrolled in a hospice program certified or paid for by Medicare or licensed by the state. This provision is directly relevant to CADD cassette ordering.
Under 42 CFR 418.106, hospices must have written policies on the management and disposal of controlled drugs in the patient's home, must provide a copy of those policies to the patient or representative and family in understandable language when controlled drugs are first ordered, and must document that discussion in the clinical record.
Clinical details for prescribers
Infusion titration framing. A structured approach reported in the palliative literature is: convert the current 24-hour opioid requirement to an intravenous or subcutaneous equivalent; divide by 24 to obtain the basal rate; give a loading bolus, because steady state takes hours to reach; set demand boluses at 50 to 150 percent of the hourly rate with a lockout of about 20 minutes; and reassess every 30 to 60 minutes until symptoms are controlled. The instruction to start morphine at 1 mg per hour and titrate to effect is pharmacologically unsound in an opioid-tolerant patient and is not a defensible default. All dosing decisions remain the prescriber's.
Cassette sizing. Volume is a function of the ordered rate multiplied by the intended interval between nurse visits, bounded by the roughly 3 mL/hr subcutaneous absorption ceiling. Specify concentration, total volume, and the intended interval on the order so the cassette can be built to match the visit schedule.
Route. Continuous subcutaneous infusion is used when the oral route fails and intravenous access is absent or burdensome at home. Morphine, hydromorphone, fentanyl, and sufentanil are all described as suitable subcutaneously. A 25- or 27-gauge butterfly placed in the upper arm, shoulder, abdomen, or thigh, avoiding the chest wall, may remain up to about a week absent a local reaction; rotate for redness, induration, or leakage and avoid edematous or irradiated tissue. Intravenous-to-subcutaneous conversion evidence is weak; many practitioners use 1:1.
Points frequently raised on order review:
- Incomplete cross-tolerance: a 25 to 50 percent reduction is customary when rotating opioids; published conversion ratios are approximations
- Renal impairment: morphine M3G/M6G and the hydromorphone glucuronide accumulate; reported reductions are about 25 percent at CrCl 10 to 50 mL/min and about 50 percent below 10 mL/min; fentanyl and methadone have no active metabolites
- Neurotoxicity presents as myoclonus, hyperalgesia, and agitated delirium, not simply sedation
- Midazolam combined with an opioid infusion is the highest-risk combination in this catalog
- Oral concentrates of morphine, lorazepam, and haloperidol are FDA-approved commercial products; note the shortage or the patient-specific need (dye-free, alcohol-free, flavor, concentration) on the prescription
- Dexmedetomidine in palliative care is emerging and investigational; bradycardia and hypotension are dose-limiting
- Lorazepam topical gel: no absorption or efficacy claim is made; see Smith 2012
- Beyond-use dates are assigned per USP <797> category and the testing performed, and are printed on the label
Ordering: e-prescribe or fax a patient-specific prescription to Bayview Pharmacy, NCPDP 4106882, fax 401-284-4506. For Schedule II preparations compounded for direct parenteral infusion, for long-term care facility residents, and for hospice patients, the facsimile serves as the original written prescription. Bayview does not supply office use or agency stock. Account setup, licensing, and ordering are covered on our for providers page.
These are prescription compounded preparations and are not FDA-approved. This page is educational information for licensed prescribers and clinicians and is not medical advice, a treatment recommendation, or a dosing recommendation. Doses described are reported from published literature. The prescriber determines whether any preparation, route, or dose is appropriate for an individual patient. A valid patient-specific prescription is required.
