What is the best medication for terminal restlessness in a hospice patient?

Best Medication for Terminal Restlessness in Hospice Patients

Midazolam is the first-line medication for terminal restlessness in hospice patients due to its rapid onset, multiple administration routes, and proven efficacy in palliative sedation. 1, 2

Understanding Terminal Restlessness

Terminal restlessness is a common end-of-life symptom affecting 25-88% of dying patients, characterized by agitation, confusion, and increased motor activity in the final hours or days of life 3. It significantly impacts patient comfort and family distress.

Medication Selection Algorithm

First-Line Treatment: Benzodiazepines

• Midazolam:
  • Preferred agent due to:
    • Rapid onset of action
    • Water-soluble, short-acting properties
    • Multiple administration routes (IV, SC)
    • Can be co-administered with morphine or haloperidol
  • Dosing:
    • Starting dose: 0.5-1 mg/h continuous infusion or 1-5 mg as needed
    • Usual effective dose: 1-20 mg/h
    • Administration: Continuous infusion preferred to maintain effect due to rapid redistribution 1

Second-Line Treatment: Neuroleptics/Antipsychotics

When terminal restlessness is accompanied by delirium:

• Levomepromazine (methotrimeprazine):

  • Starting dose: 12.5-25 mg
  • Usual effective dose: 12.5-25 mg every 8h with PRN dosing for breakthrough
  • Administration: IV, SC, IM
  • Added benefit: Some analgesic effect 1

• Chlorpromazine:

  • Starting dose: 12.5 mg every 4-12h (IV/IM) or 25-100 mg every 4-12h (rectal)
  • Usual effective dose: 37.5-150 mg/day (parenteral) or 75-300 mg/day (rectal)
  • Widely available and can be administered through multiple routes 1

Third-Line Treatment: For Refractory Cases

When patients develop tolerance to benzodiazepines and neuroleptics:

• Phenobarbital:

  • Dosing: 1-3 mg/kg SC/IV bolus, followed by 0.5 mg/kg/h infusion
  • Maintenance: 50-100 mg/h
  • Advantage: Anticonvulsant properties 1

• Propofol:

  • Loading dose: 20 mg, followed by 50-70 mg/h infusion
  • Consider for cases refractory to benzodiazepines and neuroleptics 4
  • Requires careful monitoring due to potent sedative effects

Important Clinical Considerations

Medication Administration

• Route selection should be based on patient condition:
  • Subcutaneous or intravenous routes are preferred in terminal stages
  • Continuous infusion maintains consistent sedation levels
  • Always provide for breakthrough dosing 1, 5

Monitoring and Titration

• Titrate to the minimum effective dose that provides symptom relief
• Regular assessment of sedation level and symptom control
• Adjust dosing based on breakthrough medication requirements 5

Common Pitfalls to Avoid

1. Misdiagnosing delirium as anxiety: Opioids or benzodiazepines as initial treatment for delirium can worsen symptoms; use antipsychotics first for delirium 1

2. Inadequate dosing: Terminal restlessness often requires higher doses than standard practice; don't hesitate to titrate appropriately 5

3. Abrupt discontinuation: Avoid sudden withdrawal of benzodiazepines to prevent rebound agitation 1

4. Neglecting non-pharmacological approaches: Consider complementary approaches like presence of family members, calming environment, and even robotic pets in appropriate cases 6

Family Support

• Explain that medications for symptom relief are unlikely to shorten the patient's life
• Provide regular updates about the patient's condition
• Encourage family presence when appropriate 5

Conclusion

While midazolam is the first-line medication for terminal restlessness in hospice patients, treatment should follow a stepwise approach based on symptom presentation and response. For cases with prominent delirium features, antipsychotics may be more appropriate initial therapy. For refractory cases, barbiturates or propofol provide effective alternatives.