Factors that predispose to terminal restlessness

Terminal restlessness is both a common and distressing symptom encountered in the last few days of life, occurring in between 25 - 88% of patients1-2, Aetiology is often multifactorial and empiric pharmacological therapy usually involves the use of antipsychotics and benzodiazepines. In our Palliative Care Unit (PCU), benzodiazepines (midazolam and clonazepam) and anti psychotics (haloperidol) are used commonly, with phenobarbitone used in refractory, severe terminal restlessness.

This case series explores factors predisposing to severe terminal restlessness, using phenobarbitone as a surrogate of the condition. The notes of patients requiring phenobarbitone were retrospectively analysed, with emphasis on their demographic data and quality of their pain on admission. Additionally, psychological or existential distress were determined and analysed by a visual analogue scale of distress on admission, or via specific mention in patient's files.

Over a 28 month period, 1454 admissions to our PCU were recorded, with 959 deaths. In this time, 17 patients required phenobarbitone to manage their terminal delirium. Of these, the mean age of the patients was 58.1; 10/17 (59%) were male and 8/17 (47%) had proven cerebral metastases. Median time since diagnosis was 12 months (range 1-160 months). Psychological and existential distress were noted in 9/17 (53%), and 10/17 (59%) had moderate to severe pain on admission (morphine> 120mg o d). 8/17 (47%) had a previous history of psychiatric disease prior to admission. Median dose of phenobarbitone used was 400mg/24hours (range 100 - 1200) and median duration of treatment with phenobarbitone until death was 16 hours (range 1.5 hours -182 hours, mean 36).

This case series supports previous cohort studies which showed that severe terminal restlessness was more prevalent in younger patients with more aggressive tumours and greater psychological distress.

1. Fainsinger R et al, Symptom control during the last weeks of life on a palliative care unit.
    J Palliat Care 1991;7:5-11.
2. Massie MJ et al, Delirium in terminally ill cancer patients,
    Am J Psychiatry 1983; 140:1048-1050.