Center to Advance Palliative Care

The standard of care for managing terminal restlessness/delirium is a major tranquilizer (e.g. haldol, thorazine). As noted by the previous post, benzodiazepines (Ativan, Valium) can lead to worsening agitation and should be reserved for special circumstances. Dosing major tranqs is like opioids; if you assume the symptom is continuous, you need a continuous order and a prn order, such as Haldol 2 mg q8 and 2 mg q1h prn. I am well aware many physicians, especially in nursing homes, avoid or even refuse to prescribe major tranqs, this is contrary to best medical evidence and should be corrected through policies and standard order sets. Of note: many cases of terminal delirium are due to palliative care meds, the biggest offenders being anticholinergics (e.g. scopolamine patches) and/or opioids (often in association with myoclonus). Consultation with a palliative care physician or APNP is warranted.
See Palliative Care Fast Facts #1 and #60 for more details and references; www.eperc.mcw.edu