Background National formularies recommend a step wise approach to Terminal Agitation (TA) using benzodiazepines and anti-psychotics.

Within our 21 bed specialist palliative care unit, a flowchart for management of TA was created in response to reviews where medical and nursing staff felt TA had been poorly controlled.

Four months after the introduction of the local guidelines, we conducted a spot survey of trained nursing staff to ascertain confidence toward management of TA.

Methods A standardised pro forma of 13 questions was used. Staff ranked confidence with various aspects of TA management using a numerical rating scale (1= lowest, to 10= highest). Free text responses were collected regarding the most rewarding and challenging aspects of managing TA.

Results 11 of 12 nurses (all female) responded. Mean age 42 years (25-56), with a mean of 15 years since qualification (<1–36), and 10 years working in palliative medicine (<1 year – 31 years, one working as bank).

Most reported confidence in recognising and managing TA as well as the specific use of midazolam, haloperidol and levomepromazine. Respondents were less familiar with phenobarbital (table).

Lowest levels of confidence in managing TA were reported in respondents with the least experience of this.

Free text replies indicated that making patients settled was the most rewarding aspect of managing TA; impact on family was another common theme.

Respondents however described a number of challenges including difficulty in recognising TA, and regarding medication decisions.

Conclusions With support of a local guideline, high levels of confidence were reported in use of first and second line medications for TA. However respondents still reported challenges in its management.

Future considerations We recommend regular education and training alongside ongoing reflection amongst medical and nursing teams after events of TA, to ensure best practice, team well-being and confidence with guidelines.