Background Terminal agitation and delirium at the end of life are common.¹Whilst anxiolytic and antipsychotic medications are widely used during the last week of life, clinical evidence regarding their use is limited.^2,3 Our aim was to audit current practice at two inpatient units.

Methods A retrospective audit was carried out of all patients who died during a four-month period (June to October 2015) at two hospices (n=75). Data were collected on whether anxiolytic and/or antipsychotic medications were used in the last week of life, the drug(s) and dose(s) administered, and the indication. Use of Levomepromazine and Haloperidol for nausea and vomiting were excluded. Audit standards were set according to guidance in the PCF-5⁴ and a compliance target of 80% was set.

Results The median age was 79 years (range 32 to 94) and 80% of patients had a primary diagnosis of cancer. In total, 91.7% (n=33) of patients at Hospice 1% and 82.1% (n=32) at Hospice 2 received anxiolytic and/or antipsychotic medications during the last week of life. The most common indication at Hospice 2 was terminal agitation (n=16, 50%), compared with mixed terminal agitation and delirium (n=11, 33.3%) at Hospice 1. Midazolam was the most widely used drug (used in 77.8% of patients at Hospice 1, n=28, and 74.4% of patients at Hospice 2, n=29). Haloperidol was more widely used at Hospice 1 whereas Levomepromazine was used more at Hospice 2. None of the patients received Phenobarbitone. Compliance with the audit standards was 65%–75%.

Conclusions Anxiolytic and antipsychotic medications were widely used in the last week of life, with variations in practice in terms of the drugs and doses used. Classification of the indication for use was inconsistent. Following the audit we developed a framework for use of these drugs at the end of life.

References

1. . Hosie A, et al. Delirium prevalence, incidence, and implications for screening in specialist palliative care inpatient settings: a systematic review. Palliative Medicine 2013;27:486–98.

2. . Beller et al. Palliative pharmacological sedation for terminally ill adults (review). Cochrane Database of Systematic Reviews 2014;Issue 1. Art. No.: CD010206.

3. . Candy et al. Drug therapy for delirium in terminally ill adult patients. Cochrane Database of Systematic Reviews 2012;Issue 11. Art. No.: CD004770. DOI: 10.1002/14651858 .CD004770.pub2.

4. . Twycross et al. Palliative Care Formulary (PCF5). Palliativedrugs.com Ltd. 5^th edition. 2014.