As the terminally ill near death, body organs and systems begin to fail to a greater and greater degree. Kidneys stop producing as much urine and function poorly, the liver and other organs also start to shut down. Waste products from the cells and tissues of the body begin to build up in the tissue spaces and blood stream. Biological and chemical balance is lost. The pH in the blood and other areas may change dramatically. In many patients, these changes alone may account for restlessness and agitation that may be quite severe.
The following steps should be taken in the management of terminal restlessness.
- Evaluate current medications to eliminate any nonessential drugs.
- Minimize stimulation by family/staff.
- Educate family regarding treatment options.
- Try non-pharmacologic treatments such as relaxation/distraction therapy or massage if appropriate. Keep in familiar surroundings.
- Implement pharmacologic treatment options if other interventions fail.
Pharmacologic treatment options most preferred are the use of a benzodiazepine and an antipsychotic. Palliative care and hospice studies have not identified an advantage of one antipsychotic over another in terminal restlessness. These medications can be used alone but are often used in combination if the terminal restlessness and agitation is severe or is not managed by one medication. Lorazepam is a drug of choice as it does not have dosing restriction based on renal or liver function and has a sublingual liquid available or the regular release tablet can be crushed and mixed with a small amount of water if unable to swallow orally. Haloperidol is a drug of choice and does not require dosing adjustments based on renal or hepatic function and is available as a liquid concentrate for sublingual administration or the tablet can be crushed and mixed with a small amount of water if unable to swallow it orally.
PMcCrate B, Kimbrel J, Grauer P. 2015 Palliative Care Consultant 4th Ed Montgomery, AL. Hospiscript