RESTLESSNESS AND AGITATION IN THE DYING PHASE ³ ⁴
In advanced illness, confusion and terminal restlessness/agitation are common.
A prognosis of only hours to days may leave insufficient time for a response to some specific treatments and therefore confusion or agitation should be managed symptomatically.
Before prescribing medication for this condition, all efforts should be made to consider non-drug intervention. For example reassurance from staff, a calm environment, the presence of relatives or carers who are close to the patient, items from home which help to orientate the patient, appropriate diurnal lighting, the possibility of one-to-one nursing.
Common causes of confusion or agitation in the dying phase
• adverse effects of medication (e.g. opioids, steroids)
• urinary retention
• uraemia/ hepatic encephalopathy
• primary brain tumour
• cerebral metastases
• spiritual distress
When considering whether or not to treat these causes of confusion or agitation, the burdens of treatment need to be weighed up against the potential for improving comfort at the end of life.
It may be difficult to address psychological causes of distress and anguish in the last few days of life. Reliance is placed on improving environmental factors and appropriately titrating sedation.
In the last days of life;
Consider using an end of life care pathway such as the Liverpool Care Pathway.
Prescribe PRN drugs as described below in anticipation of anxiety or distress caused by breathlessness. Many patients will become unable to take drugs by the oral route so prescribe medication to be given parenterally e.g. subcutaneously.
Consider stopping or reducing clinical (artificial) hydration if this is causing fluid overload leading to pulmonary oedema or excessive upper airway secretions.
Midazolam 2.5–5mg SC hourly PRN
Morphine 2.5–5mg SC 1–2 hourly PRN (higher doses of morphine may be appropriate in patients who are already receiving regular strong opioids. In patients who need repeated (hourly) doses seek specialist palliative care advice.) See Palliation of Breathlessness and Symptom control in patients with renal disease and cardiac failure.
Patients who are persistently breathless and distressed may benefit from a continuous infusion of morphine and/or midazolam – in practice try to ascertain the required dose(s) by observing and titrating according to usage of morphine or midazolam over the previous 24–48 hours.
For some patients in the dying phase it may be more practical to commence an infusion of morphine or midazolam at an earlier stage alongside the provision of additional PRN medication.
The following ranges are usually appropriate: Morphine 5–10mg sub cut infusion over 24 hours
(higher doses of morphine may be appropriate if the patient is already receiving regular strong opioids for pain)
Combining morphine and midazolam to manage breathlessness in the last days of life is common practice in palliative care.