Cambridge & Huntingdon Palliative Care Group Review Date: AUGUST 2009
FACTSHEET 9 ON PALLIATIVE CARE
TERMINAL RESTLESSNESS
TERMINAL RESTLESSNESS
aka terminal agitation/agitated delirium/terminal anguish/terminal distress.
May have
i) psychological component
• related to others e.g. ‘problematic’ family relationships which remain unresolved:
“unfinished business”
• related to self e.g. realisation that death is imminent – “crisis of knowledge”, spiritual
pain
ii) physical component
• involuntary movement: twitching, jerking, myoclonus
• purposeless movement: fidgeting, pacing, fumbling
- related to metabolic change, medication change, cerebral abnormality
• co-ordinated movement
- may be related to pain, bladder distension, constipation, nausea, pruritus etc.
N.B. Important to identify underlying cause as may be reversible.
TREATMENT
• Explanation to family with reassurance that involuntary movement not distressing to
patient
• Explore possible cause of purposeful movement and resolve e.g. catheterize
• Carry out risk assessment to ensure patient safety
• Sedation
Often requires continuous subcutaneous infusion (Refer to Factsheets 1 to 3)
ASSESS
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Cambridge & Huntingdon Palliative Care Group Review Date: AUGUST 2009
Previous medication (NB accumulation of drugs/metabolites may occur with diminishing
hepatic and/or renal function and can cause agitation).
• Is there any need to continue existing medication?
IF NECESSARY NSAIDS
Steroids can be continued as subcutaneous infusion
Anticonvulsants of equivalent drug, where necessary
NSAIDS
Diazepam can be continued via rectal route
(NB Buccal midazolam may be easier than rectal diazepam in a restless patient)
• If no pre-existing constraints base choice of sedation on recent situation.
e.g. If previous levels of anxiety mild - use midazolam, usual range 10 to 60mg per 24
hours (prn 2.5 to 5mg 2 hourly).
If, prior to terminal restlessness, agitation or paranoia existed - use levomepromazine
(Nozinan®) 50mg to 150mg per 24 hours (25mg prn 4 hourly).
Lower doses are appropriate in the frail and elderly e.g. 12.5mg prn dose with
appropriate reduction in 24 hours csci.
• Anxiolytics/sedatives - if commencing sedation in a patient already on regular
medication start at higher dose e.g. already on regular diazepam start midazolam
range 20 to 90mg per 24 hour or prn sc 5 to 10mg 2 hourly.
• Anti-emetics - a logical choice for sedation in a restless patient requiring regular anti-
emetic would be levomepromazine (Nozinan®) 50 to 150mg/24 hours csci or bolus s.c
25mgs 4 to 6 hourly prn.
REASSESS
• Dose - at each 24 hour change of infusion
• Incorporate the total amount of any bolus doses (up to the maximum specified) into the
24-hour infusion when refilled.
IF IN ANY DOUBT PLEASE SEEK SPECIALIST ADVICE
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