Terminal agitation: Information for clinicians

• Physical causes of discomfort including pain, nausea, constipation, urinary retention, itching due to opioids or organ failure
• Opioid toxicity (myoclonic jerks, confusion, pin-point pupils, hallucinations and respiratory depression). 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

• Always try non-pharmacological methods to relieve agitation e.g. presence of family, calm lighting, quiet, 1:1 care
• Lower starting doses of sedative medication in frail elderly
• Sedation is often more difficult if there is a history of alcohol or substance misuse
• The intention is to relieve suffering, not to hasten death

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

• Starting doses of the above medication will have a calming effect but will not necessarily sedate the patient. The initial aim of treatment is to give the lowest doses to maintain calm
• Do contact the local specialist palliative care team for more specific advice about prescribing if escalating doses of sedation are needed
• Agitation is one of the most difficult symptoms to manage at home and important to manage confidently as families will remember this difficult time. 
• Prescribing anticipatory medication to have at home will also help to manage symptoms.
• Haloperidol and Levomepromazine may help more than Midazolam if hallucinations or paranoia are present. Both are also useful as anti-emetics.