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94 Guideline development for the management of agitation in the last weeks of life
  1. Kate Nolan,
  2. Helen Bonwick,
  3. Claire Robinson,
  4. Mark Mills,
  5. A Griffiths,
  6. P Shepherd and
  7. N Shah
  1. Marie Curie Hospice Liverpool


Background Agitation is a distressing and common symptom at the end of life; despite this the evidence for the management of this symptom is poor.


  • Audit clinical practice around management of terminal agitation with patients and healthcare professionals (HCPs) against regional standards.

  • Use audit outcomes to update regional standards and guidelines


  • Systematic literature review examining the evidence base.

  • Survey of HCPs working in specialist palliative care.

  • Retrospective case note review of patients with a diagnosis of terminal agitation receiving specialist palliative care in hospital, hospice or community settings.

Results Below is a summary from 185 responses from 11 different healthcare settings in the Merseyside area from retrospective case note review:

  • Hospice 54.5%, Hospital 29.7%, Home 11.8%, other including Nursing homes 3%.

  • Main reversible causes documented included: pain; breathlessness: constipation and urinary retention.

  • 94% of patients had medications reviewed.

  • Non–pharmacological interventions formed part of the overall management plan.

  • 82% of patients had psychological and spiritual support offered to the patient and or family.

  • First line pharmacological intervention is Midazolam, Levomepromazine is second line.

  • In 92% of cases a Syringe driver (CSCI) was used.

  • Majority of deaths occurred in 3 days or less

  • Communication with patient and family formed a key theme.

At the time of death:

  • Midazolam prescribed in 146 cases (mean 26 mg – range 0–60 mg).

  • Levomepromazine prescribed in 61 cases (Mean 56.8 mg – range 5–250 mg).

  • Haloperidol 25 cases (Mean 3.5 mg – range 1–8 mg).

  • Phenobarbital 9 cases ( Mean 922 mg – range 200–1200 mg).

Conclusion This Audit revealed the challenges and wide variation in practice with regards to management of terminal agitation. These findings have informed an update of the regional palliative care guidelines.

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