As the patient becomes closer to the last weeks or days of life, they may exhibit delirium and agitation symptoms. This agitation is also referred to as terminal restlessness.
Delirium can increase markedly from 12% to 88% among palliative care patients in the last weeks of life. Delirium is associated with increased mortality and can increase the risk of falls and the patient and family's psychological stress (Bush, 2017).
Delirium is classified as a neurocognitive syndrome arising from brain dysfunction (Bush, 2017). It has been subtyped into hyperactive motor subtype or hypoactive motor subtype based on whether the patient is restless and agitated or lethargic and quiet (Evenson et al., 2019).
Symptoms of delirium include the following:
Some treatable causes of mild delirium include the following:
In severe delirium and agitation, antipsychotic medications such as haloperidol and risperidone can be useful. In very severe cases, palliative sedation can be used (Albert, 2017).
Delirium and agitation versus end-of-life communication
It is important to consider patients nearing the end of life as possibly having a transpersonal end-of-life experience that needs to be distinguished from delirium and agitation. During an end-of-life communication, a patient may say they see, hear or feel the presence of a deceased person.
According to Lawrence (2013), during a transpersonal end-of-life experience, the patient is oriented to time, person, and place. The only extraordinary experience is communication with a deceased person. Also, these experiences tend to be short-lived, lasting seconds to just a few minutes. Drug-induced hallucinations and confusion encompass a lack of orientation to time, person, and place and are more likely to be continuous states. End-of-life experiences have a dramatic, positive effect on the dying person. Typically, the person feels less anxious, calm, and occasionally elated, leading to the need for less medication. For more information, go to the Near-death and other transpersonal experiences course on the RnCeus Interactive website.
If palliative care patients see deceased relatives, they should receive sedation even when oriented to person, time, and place.
Albert, R.H. (2017). End-of-Life Care: Managing Common Symptoms. Am Fam Physician. 95(6), 356-361.
Bush, S. H., Tierney, S. & Lawlor, P. G. (2017). Clinical assessment and management of delirium in the palliative care setting. Drugs. 77, 1623-1643.
Evensen, S., Saltvedt, I., Lydersen, S., Wyller, T.B., Taraldsen, K. Sletvold, O. (2019). Delirium motor subtypes and prognosis in hospitalized geriatric patients - A prospective observational study. J Psychosom Res. 122, 24-28.
Lawrence, M. & Repede, E. (2013). Incidence of deathbed communications and their impact on the dying experience. American Journal of Hospice and Palliative Medicine. 30, 632-639.
Ganzini, L. (2007). Care of patients with delirium at the end of life. Annals of Long-Term Care. 15(3)