INTRODUCTION
Restlessness and agitation during the terminal phase is a distressing problem, which can be difficult to manage. As with all other symptoms, the cause of restlessness needs to be identified and if at all possible reversed. Terminal restlessness is often “a pre-death event”.
DEFINITION
Delirium occurring in the last days of life is often referred to as terminal restlessness or agitation. In the last 24-48 hours of life, it is most likely caused by the irreversible processes of organ failure.
ASSESSMENT
Physical discomfort
- Unrelieved pain
- Distended bladder
- Full bowel
- Physical restraint
- Insomnia
- Uncomfortable bed
- Nicotine/alcohol or medication withdrawal
- Puritis (itch)
- Metabolic change
- Unfamiliar environment
- Medication toxicity
Psychological discomfort
- Feelings of hopelessness
- Helplessness
- Anger
- Guilt
- Fear
- Spiritual discomfort
- Unfinished business
Do any of the following apply?
- Distressed vocalization - the person does not know what to do with his/her self “something is not quite right”
- Involuntary movement - twitching, jerking, myclonus
- Purposeful Movement - fidgeting, pacing, fumbling, “Plucking”
MANAGEMENT
A holistic, multi-disciplinary assessment is undertaken to consider the physical, social, cultural, spiritual and emotional needs of the person.
Treat and/or remove possible causes:
- Change position
- Check bladder/bowels
- Ensure patient safety
- Use of a sitter
- Low stimulus environment
- Familiar voices, pictures, belongings
- Gentle massage/aromatherapy
- Spiritual guidance or support
- Lower bed to the ground
- Assist with smoking or nicotine patch/application
- Sensor mats in place
- Too hot/cold body temperature and environment
- Religious guidance (if it is the person/family/whanau wishes)
- Involvement of and explanations to person and family/whanau
