Introduction A tool was created to guide management of terminal agitation. The patient is assessed and treated for reversible causes. If symptoms continue, patients are assessed against the modified Richmond Agitation-Sedation Scale (mRASS). This was initially developed to assess agitation in intensive care1 but has been modified and validated for use in palliative care.2 Staff then follow a flowchart for medication doses in response to recalculated mRASS scores.
Methods A retrospective audit was completed after 6 months. This included all patients who died in the hospice during July 2019. A staff survey was also circulated.
Results 21 patients died in total, of whom 16 (76%) required medicinal intervention for agitation. All patients had an assessment for reversible causes of agitation on a per shift basis. When medication was required, an appropriate low dose of benzodiazepine was used first line in 100% cases. This dose was titrated to response in 75% of cases with 1 out of 4 repeating the same dose despite failure to settle symptoms. Patients were escalated to levomepromazine in 100% of cases. Only one case may have benefitted from a higher dose of levomepromazine, but a repeated lower dose was administered. No patients required escalation to third line phenobarbitone.
Five nurses responded to the survey. 100% found the tool helpful, felt more confident in what medication to use and knew when to contact a doctor. 80% felt more confident in escalating doses with 1 saying this would improve with repeated use of the tool. 80% felt using the tool had made a positive difference for their patient, 1 patient‘s symptoms being more complicated to settle.
Conclusions The tool is effective in supporting management of terminal agitation and received positive feedback from staff. Appropriate escalation of doses is likely to improve with repeated use of the tool.
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