Palliative Care
in Dumfries and Galloway
Staff Area
Also known as terminal restlessness or terminal delirium, patients may present with:
• Extreme restlessness
• Fluctuating episodes of cognitive decline
• Worsening of pre-existing delirium
• High levels of existential distress
Management:
- Respond calmly and offer to explain what is happening to family and friends of the person
- Examine the patient to exclude treatable causes of distress, for example too hot or cold, urinary retention, dry mouth, faecal impaction, itch or rash, poorly controlled pain, drug toxicity (The TIMEBUNDLE is a tool developed by Healthcare Improvement Scotland to identify causes of delirium – download here)
- Reduce polypharmacy. Stop haloperidol.
- If opioid toxicity suspected reduce dose by 50% and observe
- Midazolam SC 2mg to 5mg, hourly, as required
For patients with persistent anxiety/distress:
Strongly consider referral to specialist palliative care for ongoing support and advice. In and out of hours advice is available via Switchboard (100 internally 01387 246246 externally)
For patients with persistent anxiety/distress:
First step:
Midazolam SC 10mg to 20mg over 24 hours in a syringe pump +
midazolam SC 5mg hourly, as required.
Second step:
Titrate Midazolam with advice starting at 10 mg over 24 hours in a syringe pump. Doses can be gradually titrated up to 60mg over 24 hours
under specialist advice.
Additional steps:
Levomepromazine may need to be used in addition to midazolam under specialist advice.
Use lower doses if not used previously and in frail elderly, for example, 2.5mg to 5mg SC as required 2 hourly. Higher doses may be needed for persistent distress or delirium for example, 10mg to 25mg SC as required 2 hourly.
May need to be given more frequently initially, for example, hourly to control symptoms.
Stop any haloperidol if using Levomepromazine.