At what stage of terminal illness does terminal agitation occur?

From the Guidelines

Terminal agitation typically occurs in the final hours or days of life, often when a patient is nearing death 1. It is generally seen in patients who are within 24 to 48 hours of death, although the exact timeframe can vary.

Key Characteristics

• Terminal agitation is usually refractory in the dying phase 1
• Patients exhibiting signs of terminal agitation should be closely monitored and considered for pharmacological interventions to alleviate symptoms and promote patient comfort

Treatment Options

• Midazolam (2.5-5mg orally or subcutaneously every 1-2 hours as needed) is a commonly prescribed medication for palliative sedation 1
• Haloperidol (0.5-1mg orally or subcutaneously every 1-2 hours as needed) is also an option for managing terminal agitation
• The dosage and duration of treatment should be tailored to the individual patient's needs and medical condition 1

Important Considerations

• Palliative sedation may be necessary in cases of refractory suffering when death is imminent 1
• Patients should be advised that lucidity may not be restored after palliative sedation, and that symptoms may reoccur or death may intervene 1

From the Research

Terminal Agitation Stage

Terminal agitation can occur at various stages of terminal illness, but it is most commonly associated with the final days or weeks of life.

• According to a study published in 2008 2, delirium, which can include agitation, is a common complication in patients with advanced illness, occurring in up to 85% of patients in the last weeks of life.
• A 1990 study 3 found that restlessness and confusion are common symptoms in the last 48 hours of life, suggesting that terminal agitation can occur in the final days of life.
• Another study published in 2022 4 mentions that terminal agitation may be an additional problem in the dying phase, along with death rattle and delirium.

Timing of Terminal Agitation

The exact timing of terminal agitation can vary depending on the individual patient and their underlying condition.

• A 2011 study 5 found that only 51% of patients received medication to alleviate agitation and restlessness in the last 24 hours of life, suggesting that terminal agitation can occur in the final hours or days of life.
• A 2024 study 6 compared the effectiveness of different pharmacological treatments for agitated delirium in the last days of life, suggesting that terminal agitation can occur in the final days or weeks of life.

Factors Contributing to Terminal Agitation

Terminal agitation can be caused by a variety of factors, including:

• Underlying medical conditions, such as infection, organ failure, and medication adverse effects 2
• Metabolic disorders associated with multi-organ failure 3
• Irreversible causes, such as advanced cancer 6