Terminal Agitation: Information for clinicians

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

West Midland Palliative Care - Restlessness and Agitation in the Dying Phase

Published 7th October 2024

Mid and South Essex Palliative Care Formulary

Published 1st October 2024

Share

Downloads

Related Services

Hassengate Pharmacy
Close

Hassengate Pharmacy

T. 01375 641569

A community pharmacy which stocks common palliative medicines to support people being cared for at home

Address: Hassengate Medical Centre, Southend Road, Stanford-le-Hope, SS17 0PH

Opening hours: Monday 8.00am to 10.30pm. Tuesday 7.00am to 10.30pm. Wednesday to Saturday 8.00am to 10.30pm. Sunday 9.00am to 10.00pm.

St Francis Hospice Referral Hub
Close

St Francis Hospice Referral Hub

T. 01708 758606

W. https://www.sfh.org.uk/make-a-referral

The St Francis Hospice's referral hub can be accessed by those facing a life limiting condition. 

Please refer a patient or making a self-referral to access hospice services.

St Luke's Hospice Community Service
Close

St Luke's Hospice community service provides assessment, support advice and care for people wishing to be cared  and supported in their locality community setting. The team also provide support in care homes, the hospice's rapid access service and there is the provision of clinical nurse specialists.

Related Articles

1st October 2024

Anticipatory Prescribing: Information for clinicians

30th April 2024

Delirium: Information for clinicians

Feedback