Restlessness and Agitation in the Dying Phase

In advanced illness, confusion and terminal restlessness/agitation are common.

A prognosis of only hours to days may leave insufficient time for a response to some specific treatments and therefore confusion or agitation should be managed symptomatically.

Before prescribing medication for this condition, all efforts should be made to consider non-drug intervention. For example reassurance from staff, a calm environment, the presence of relatives or carers who are close to the patient, items from home which help to orientate the patient, appropriate diurnal lighting, the possibility of one-to-one nursing.

Common causes of confusion or agitation in the dying phase:

  • Adverse effects of medication (e.g. opioids, steroids)
  • Pain
  • Constipation
  • Urinary retention
  • Hypoxia
  • Hypercalcaemia
  • Infection
  • Uraemia/ hepatic encephalopathy
  • Primary brain tumour
  • Cerebral metastases
  • Spiritual distress

When considering whether or not to treat these causes of confusion or agitation, the burdens of treatment need to be weighed up against the potential for improving comfort at the end of life.

It may be difficult to address psychological causes of distress and anguish in the last few days of life. Reliance is placed on
improving environmental factors and appropriately titrating sedation.


This Guide is intended for use by healthcare professionals and the expectation is that they will use clinical judgement, medical, and nursing knowledge in applying the general principles and recommendations contained within. They are not meant to replace the many available texts on the subject of palliative care.

Some of the management strategies describe the use of drugs outside their licensed indications. They are, however, established and accepted good practice. Please refer to the current BNF for further guidance.

While WMPCPS takes every care to compile accurate information , we cannot guarantee its correctness and completeness and it is subject to change. We do not accept responsibility for any loss, damage or expense resulting from the use of this information.