Terminal Agitation: Information for clinicians

This information is sourced from WM Cares Guidelines, PANG Guidelines, Scottish Palliative Care Guidelines, CNWL, Marie Curie and North West London ICS

Confusion, restlessness and agitation are common symptoms at the end of life and require a careful physical assessment.

Often the cause is due to many factors, and the first question is whether the patient is in their final days. Consider reversible causes and what treatments are appropriate at this stage of life. Agitation and confusion may be a sign that life is coming to an end and the best approach may be to focus on keeping the person calm.

Consider the following causes
  • Physical causes of discomfort including including pain, nausea, constipation, urinary retention, itching due to opioids or organ failure
  • Opioid toxicity (myoclonic jerks, drowsiness, confusion, pin-point pupils, hallucinations, reduced cognition and respiratory depression as a late sign). If this is suspected, consider reducing the opioid by 30-50% or an opioid switch 
  • Metabolic causes (hypoxia, hypercalcaemia, renal and liver failure, nicotine withdrawal)
  • Infection with delirium
  • Cerebral metastases
  • Spiritual and psychological distress
Key Points
  • Do contact the local specialist palliative care team for more specific advice about prescribing if escalating doses are not helping
  • Lower starting doses in frail elderly.
  • Sedation is often more difficult if there is a history of alcohol or substance misuse.
  • Try non-drug methods to relieve agitation first.
  • The intention is to relieve suffering, not to hasten death
Symptom management

Consider simple interventions such as 1-1 nursing if possible, reassurance and presence of staff or loved ones, a calm environment, lighting, familiar surroundings or objects.

The following drugs are commonly used for management of agitation at the end of life.

Haloperidol 2.5mg S/C Stat 5mg -10mg per 24h via CSCI
Midazolam 2.5mg-5mg S/C or buccal Stat 10-60mg per 24h via CSCI
Levomepromazine 12.5-25mg S/C Stat 25-150mg per 24h via CSCI
  • The above medication in starting doses will have a calming effect and will not necessarily sedate the patient. The initial aim of treatment is to give the lowest doses to maintain calm
  • Deeper sedation may be needed if agitation worsens. It is one of the most difficult symptoms to manage at home and important to manage confidently as family will remember this difficult time. Advice for families caring at home is essential. Prescribing anticipatory medication to have at home will also help to manage a crisis.

Sources

PANG Guidelines Quick Guide Agitation and Restlessness

Published 16th October 2016

PANG Guidelines Last Days – Agitation

Published 13th October 2016

Scottish Palliative Care Guidelines – Severe Uncontrolled Distress

Published 22nd April 2020

Marie Curie – Agitation – Causes and How to Manage

Published 1st September 2018

CNWL Supporting excellent care in the last days of life at home

Published 1st April 2017

CNWL Anticipatory medicines – a guide for families

Published 1st July 2020

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