Crisis pathway
- Discharged home with no medicines or plan
- Cannot swallow; pain and agitation at midnight
- Overnight transfer to an ICU far away
- Dies in ICU, apart from family, with heavy debt
End-of-life care · India
A peaceful death is a human right.
How anticipatory “Just in Case” medicines could reach every home in India, so that no dying person waits in distress for a prescription.
The starting point
Dying in comfort is a reasonable expectation, not a clinical luxury.
Freedom from uncontrolled pain, breathlessness and distress is what we would all want for our families. Nothing here needs new science.
“The gap in India is less about clinical capability and more about policy, supply and confidence, which means it can be fixed.”
01
Inexpensive medicines
The medicines cost little and the clinical knowledge is long established.
02
Not yet reaching India
Most people approaching the end of life in India still do not have them.
03
A structural gap
Policy design, supply infrastructure and prescriber confidence.
Why it is a right
Pain relief is a right. So is a peaceful death.
The same rights apply with particular force in the last days of life, when swallowing fails and help must already be in the home.
International law
ICESCR Article 12 protects the right to the highest attainable standard of health. UN General Comment 14 treats access to essential medicines as a core state obligation.
World Health Assembly
Resolution 67.19 (2014) calls on all states to build palliative care into primary health care and to ensure access to essential medicines, including opioids.
Indian Constitution
Article 21’s right to life includes dignity in dying (Common Cause v Union of India, 2018). A 2023 order simplified how advance directives are made.
PART 1 · THE UK MODEL
What is Just in Case prescribing?
Also called anticipatory prescribing: the proactive supply of injectable medicines, held in the patient’s home before symptoms arise, so that help is there at 2 am on a Sunday, not hours later.
Pain
Breathlessness
Agitation
Nausea
Respiratory secretions
What goes in the box
Core medicines, given under the skin
| Symptom | Commonly used in UK practice | Class |
|---|---|---|
| Pain, breathlessness | Morphine (or oxycodone) | Opioid |
| Agitation, distress | Midazolam | Benzodiazepine |
| Nausea, vomiting | Cyclizine, levomepromazine or haloperidol | Antiemetic |
| Respiratory secretions | Hyoscine butylbromide or glycopyrronium | Antimuscarinic |
| Diluent | Water for injection | — |
One drug often covers two symptoms. A small, cheap, largely generic list. Choice and doses follow local formularies and kidney function; doses are deliberately not shown.
In practice
The life of a Just in Case box
Prescribe
When the person is recognised as likely to be in the last weeks of life, ideally alongside advance care planning.
Store
A sealed, labelled box at home, out of reach of children, with the authorisation chart beside it.
Check
Stock and expiry checked on visits; controlled drugs counted and recorded.
Administer
Community nurses, and trained carers where policy allows, give doses promptly when symptoms appear.
Behind the box
The governance that makes it safe
Every element is low-tech: a paper chart, a stock record, a training session, a shared record. This is what gives prescribers and regulators confidence.
Authorisation chart
Signed indications, dose ranges and maximum frequency, kept in the home.
Controlled drug records
Stock counts, administration records and safe disposal after death.
Training
Prescribers, community nurses and, where used, family carers.
Review
Regular review of use; escalation if doses are needed repeatedly.
Communication
Shared records so out-of-hours teams know the box exists.
Family conversation
What the medicines are for, and what they are not for. Addressing fears that they hasten death is part of the governance.
What transfers
Essential versus incidental
Essential anywhere
- Medicines in the home before they are needed
- A small, standard formulary
- Clear written authorisation for each drug
- A trained person who can give an injection under the skin
- Honest conversation with the family
Incidental to the UK
- Specific branded boxes and packaging
- Electronic prescribing and shared records
- Exact staffing models and job titles
- 24/7 district nursing as currently organised
- Particular drug choices where equivalents exist
PART 2 · INDIA
The gap is policy, supply and confidence. Not clinical capability.
The clinical skills exist in India. What is missing at scale is the system around them.
Medical morphine use in India collapsed after 1985
National medical consumption, indexed (1985 = 100)
Source: Human Rights Watch, Unbearable Pain (2009).
61 million
people each year live with serious health-related suffering
Over 80%
of that suffering is in low- and middle-income countries
Under 1%
of medical opioids reach the poorest half of the world
67th of 80
India in the 2015 Quality of Death Index (40th of 40 in 2010)
Sources: Knaul et al., Lancet Commission on Palliative Care and Pain Relief (2018); Economist Intelligence Unit, Quality of Death Index (2010, 2015).
Quality of Death Index 2015: overall score out of 100
Selected countries out of 80. Mongolia shows what a lower-income country can achieve.
Show as table
| Country | Rank (of 80) | Score |
|---|---|---|
| UK | 1 | 93.9 |
| Taiwan | 6 | 83.1 |
| Mongolia | 28 | 57.7 |
| India | 67 | 26.8 |
| Iraq | 80 | 12.5 |
Source: The Economist Intelligence Unit, The 2015 Quality of Death Index, Figure 1.2.
The legal landscape
From the 1985 NDPS Act to the 2014 amendment
India is one of the world’s largest producers of licit opium, yet had some of the lowest medical morphine use in the world.
1985–2014: the original Act
- Separate licences from several state departments just to stock morphine
- Fear of severe penalties for paperwork errors
- Hospitals and pharmacies stopped stocking opioids
- Medical morphine use fell about 97%, to 18 kg nationally by 1997
2014 amendment and 2015 Rules
- Six Essential Narcotic Drugs: morphine, fentanyl, methadone, oxycodone, codeine, hydrocodone
- Uniform central rules; one approval from the State Drug Controller as a Recognised Medical Institution (RMI)
- Government hospitals are deemed RMIs if they meet the requirements and file annual consumption reports
- Uptake remains uneven between states
The reform followed years of campaigning by Pallium India, Dr M.R. Rajagopal, the Indian Association of Palliative Care and others. Law on paper is not yet access in practice.
The 2014 amendment in detail
The problem it was fixing
The 1985 Act was built almost entirely around stopping drug trafficking. Strong opioids were regulated by each state (section 10), and many states required several licences from different departments, each with its own renewals. Many hospitals and pharmacies stopped stocking oral morphine because it was not worth the bureaucratic and legal risk.
What the amendment changes
Medical use becomes a stated purpose of the law. The Central Government must now ensure narcotic drugs are available for medical and scientific use, not just prevent misuse, a statutory duty advocates can point to.
A new category, “essential narcotic drugs”. In 2015 six were notified: morphine, fentanyl, methadone, oxycodone, codeine and hydrocodone.
Licensing moves to uniform central rules. Recognised Medical Institutions can stock and dispense them; the State Drug Controller is the single licensing authority; RMIs need staff trained in pain relief and palliative care. Existing state licences stayed valid for up to 12 months so supply was not disrupted.
Treatment and management. The Government can establish or recognise centres for treatment of drug dependence, part of a wider shift from purely punitive policy towards public health.
The parts that cut the other way
The amendment also doubled the maximum sentence for “small quantity” offences from 6 months to 1 year, let officers down to sub-inspector rank search licensed manufacturers, and expanded forfeiture of property.
Why access is still limited
Four kinds of barrier
The barriers reinforce one another: little training → little prescribing → little demand on the supply chain → pharmacies stop stocking opioids → even less experience for the next generation of doctors.
Clinical illustration
Three journeys at the end of life
Illustrative composite cases, not real patients. Pathway C is a proposed model, not current practice.
Anticipatory prescribing
- Advance care plan and Just in Case box at home
- Nurse gives injections from the box
- Syringe driver started at home
- Dies comfortably at home with family
Adapted pathway
- The primary health centre, as a recognised institution, issues a lockable kit
- A palliative nurse visits; a butterfly needle is sited so doses need no new needle
- Unused drugs are returned to the institution
- Dies peacefully at home, without debt
PART 3 · BUILDING ON KERALA
Kerala has already built the foundation.
Kerala already has what the rest of India needs. Anticipatory kits are the natural next step, and Kerala is the obvious place to pilot them.
1
Community ownership
NGOs, neighbourhood networks and panchayat-funded home care under the 2008 and 2019 state policies.
2
Morphine in primary care
Opioids through primary health centres and palliative institutions, with nurse-led home visits.
3
Next: kits at home
Home care teams already visit. A kit in the home lets them, and families, act at once.
A proposal for India
A tiered anticipatory kit
Oral and under-the-tongue routes first; injections where a nurse or confident carer is available. Builds on India’s own PALCARE home-care guidelines, which include anticipatory prescribing at the end of life.
TIER 1 · ORAL AND SUBLINGUAL
First line, where daily nursing visits are not available
- Oral morphine solutionGiven into the cheek or under the tongue · pain, breathlessness
- Sublingual lorazepamAnxiety, agitation
- Oral haloperidolNausea, delirium
- Sublingual atropine 1% dropsSecretions
TIER 2 · SUBCUTANEOUS
When trained staff are available or the oral route fails
- Morphine, midazolam, haloperidol and cyclizine injectionsThe same core classes used in the UK box
- Butterfly needle sited by a nurseSo a healthcare provider can give doses without a new needle each time
- Lockable box, syringes, saline flushes and sharps binSafe storage at home
- Unused drugs returnedFor reconciliation by the issuing institution
Points to resolve before rollout
- Sublingual use of atropine eye drops is off-label.
- Midazolam and lorazepam are psychotropic substances, not Essential Narcotic Drugs, so state rules for them need checking.
- Carers giving doses through a pre-sited butterfly needs support from state nursing councils and clear standing orders.
A proposal for discussion, not prescribing guidance. Doses are deliberately omitted.
How can we achieve this in India?
A roadmap from law on paper to a kit in every home
Eight steps towards a national framework. The barriers are structural, not immovable.
- 1
Make every eligible institution a working RMI
Government hospitals are already deemed Recognised Medical Institutions if they meet the requirements. Activate them in practice, with trained staff and annual consumption reporting.
State Drug Controllers · health departments - 2
Adopt one simple anticipatory protocol
Build on the PALCARE guideline: a short standard formulary, a template authorisation chart and clear review rules.
Palliative care bodies · health ministry - 3
Give nurses and carers clear standing orders
Authorise palliative nurses to administer, and trained family carers to give doses through a pre-sited butterfly needle.
State nursing councils - 4
Settle the psychotropic question
Clarify how state rules treat midazolam and lorazepam in a home kit, so prescribers are not left guessing.
Regulators · state governments - 5
Fix supply
Realistic quotas, reliable stocks of cheap generic oral morphine, and a simple return-and-reconcile system for unused medicines.
Drug controllers · procurement - 6
Train, and talk
Bedside palliative training in medical colleges, roles for community health officers and ASHAs, and honest conversations with families about what the medicines are and are not for.
Medical & nursing colleges · communities - 7
Pilot in Kerala, and measure it
Add kits to existing home-care teams. Measure place of death, crisis admissions, symptom control, safety and cost, adding evidence the field currently lacks.
Kerala home-care networks · panchayats - 8
Scale into a national framework
Adapt the model to each state’s community nursing capacity and regional diversity.
National and state governments
Structural, not immovable
No dying person should wait in distress for a prescription.
The UK model is simple at its core. India’s barriers are structural rather than immovable. Kerala proves local ownership works. A national framework adapted to India is achievable.