From the Guidelines
For terminal hallucinations in someone who is dying, palliative sedation should be considered after consultation with a palliative care specialist and/or psychiatrist, as it can be an effective option for refractory delirium. When it comes to managing terminal hallucinations, the primary focus should be on symptom management and family support 1. Neuroleptic medications, such as haloperidol, can be used to manage delirium symptoms, but their dose may need to be increased and/or their route of administration changed to ensure adequate symptom management 1.
- Key considerations for managing terminal hallucinations include:
- Removing unnecessary medications and tubes to minimize discomfort and stress
- Using palliative sedation as a last resort for refractory delirium after consulting with a specialist
- Focusing on maintaining a calm environment, providing reassurance, and ensuring adequate lighting to reduce visual misperceptions
- It's essential to prioritize the patient's comfort and dignity, rather than trying to eliminate all hallucinations, especially if they are not causing the patient distress 1.
- In terms of specific medications, neuroleptic and benzodiazepine medications can be effective in managing delirium symptoms, but their use should be carefully considered and monitored 1.
From the Research
Medications for Terminal Hallucinations
- The most commonly used medications for terminal hallucinations include haloperidol, risperidone, olanzapine, and chlorpromazine 2, 3, 4.
- Haloperidol may slightly worsen delirium symptoms compared with placebo, and may increase extrapyramidal adverse effects 2.
- Risperidone may also slightly worsen delirium symptoms compared with placebo, and may increase extrapyramidal adverse effects 2.
- Chlorpromazine and levomepromazine may be effective and safe for terminal agitation, with an advantage of not needing to change medications 3.
- A study comparing haloperidol, chlorpromazine, and levomepromazine found that all three medications may be effective and safe for terminal agitation 3.
Effectiveness of Medications
- There is low-quality evidence to support the use of haloperidol, risperidone, and olanzapine for delirium symptoms in terminally ill adults 2.
- A study found that quetiapine and ziprasidone may have faster decreases in hallucination scores compared with risperidone 5.
- Another study found that haloperidol, chlorpromazine, and a combination of haloperidol and chlorpromazine may reduce agitation in patients with terminal agitation 4.
Limitations and Considerations
- The diagnosis of hallucinations in palliative medicine may be limited, and a more biographical and cultural approach to unusual perceptions at the end of life may be necessary 6.
- The evidence for the effectiveness of medications for terminal hallucinations is largely based on low-quality studies, and further research is needed to determine the best treatment options 2, 3, 4.