… not all moaning, twitching, agitation or other new symptoms near the end of life are due to ‘terminal restlessness’. See the summary on delirium at end-of-life.
slides 7-8-9 list common things that might be going on
slides 10-11-12-13 give some (non-pharmacologic) inteventions to try
A common cause of new symptoms (twitching, restlessness, moaning) or change in behavior (agitation, crying out) is build up of toxic metabolites of opiates due to decreased metabolism/hepatic/renal function during the last days of the dying process (slides 15-16). These symptoms are often identified as increased pain and the infusion is titrated up or more boluses are used, exacerbating the problem.
Some questions to ask … How do we know that pain is causing the symptoms they are having? Is this how they have been expressing their pain? … What is their urine output? … Why have caregivers been hitting the bolus button? … What exactly is the concern?
The most difficult aspect of this scenario is to recognize what is going on … it’s often hard to see the forest when you’re in the middle of the trees. Once the situation is correctly identified, the caregivers/family need to be educated and given other ‘things to do’ (instead of hitting the bolus).
The infusion rate should be cut in half (or the basal stopped) and a reasonable bolus made available. Depending on the overall situation and symptoms – haloperidol and/or lorazepam may be appropriate.