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, agitation and restlessness are common towards the end of life due to many factors, and the first question is whether there is an easily reversible cause (e.g. urinary retention). Consider all reversible causes and what treatments are still appropriate at this stage of life.

Agitation may be a sign that life is coming to an end and the best approach may be to focus on keeping the person calm. Careful discussion is needed with care givers to explore options.

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, 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
Top Tips
  • lways try non-pharmacalogical methods to relieve agitation eg 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
Symptom management

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
  • 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.

Recommended Resources

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

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