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Terminal agitation—also known as terminal restlessness—is a common and distressing symptom in the final days or hours of life for some patients receiving palliative care. It's important for both clinicians and caregivers to recognize and manage it appropriately to ensure patient comfort.
🔍 What Is Terminal Agitation?
Terminal agitation is a neuropsychiatric syndrome characterized by:
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Restlessness
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Anxiety
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Delirium
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Moaning or calling out
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Pulling at clothes or bedclothes
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Increased movement or attempts to get out of bed
It typically occurs in the last hours to days of life and may reflect underlying physiological, psychological, or spiritual distress.
🧠 Possible Causes
Terminal agitation is often multifactorial. Common causes include:
| Category | Examples |
|---|---|
| Metabolic | Hypercalcemia, uremia, liver failure |
| Medications | Opioid toxicity, anticholinergics, withdrawal |
| Infections | Sepsis, urinary tract infections |
| Hypoxia | Reduced oxygenation due to respiratory decline |
| Delirium | From any number of organic or environmental causes |
| Psychological | Unresolved fears, anxiety, trauma |
| Spiritual or existential distress | Fear of death, guilt, unfinished business |
🩺 Clinical Approach
1. Assessment
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Identify reversible causes (e.g., opioid toxicity, infection).
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Use tools like the Confusion Assessment Method (CAM) or palliative-specific delirium scales.
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Collaborate with the care team and family to determine goals of care.
2. Non-Pharmacological Interventions
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Reassure with a calm, familiar environment.
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Gentle reorientation if appropriate.
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Minimize sensory overload (noise, lights).
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Family presence can be grounding and comforting.
3. Pharmacological Management
If symptoms are severe or distressing:
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Antipsychotics:
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Haloperidol (first-line, low-dose)
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Levomepromazine or Olanzapine (alternative)
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Benzodiazepines:
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Midazolam (esp. in refractory agitation or palliative sedation)
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Caution: May worsen delirium in some cases
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Opioid adjustment:
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If opioid toxicity is suspected, consider dose reduction or rotation
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4. Palliative Sedation
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For refractory agitation causing intractable suffering at the end of life.
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Medications: Midazolam, Levomepromazine, Phenobarbital
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Requires clear documentation and ethical decision-making involving the care team and family.
💬 Communicating With Families
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Explain that agitation can be part of the natural dying process.
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Reassure that the goal is comfort, not hastening death.
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Offer emotional and spiritual support.
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Involve palliative care or hospice teams if not already done.
📝 Quick Reference
| Symptom | Likely Cause | Intervention |
|---|---|---|
| Confusion, agitation | Delirium | Haloperidol, reduce stimulation |
| Moaning, restlessness | Spiritual distress or dyspnea | Opioid titration, chaplaincy |
| Pulling at lines/clothes | Hypoxia or pain | Oxygen, assess for discomfort |
| Severe, unresponsive agitation | Refractory delirium | Consider palliative sedation |
Would you like:
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A printable quick reference sheet?
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A decision tree for clinical use?
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Info on medications and dosing protocols?
Let me know how you'd like to apply this!
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