This site is intended for healthcare professionals

Sign in
Go to /sign-in page

You can view 5 more pages before signing in

Haloperidol in restlessness in the dying phase (in palliative care)

Authoring team

  • in advanced illness confusion and mild to moderage degrees of terminal restlessness are common
  • severe agitation, anguish or aggression with risk to self or others is fortunately rare
  • consider and appropriately treat remediable causes:
    • 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

If the patient is distressed or at risk, sedation is the mainstay of treatment

Oral PRN

SC stat

SC 24-hour syringe driver*

Midazolam*

Especially if anxiety/restlessness predominates

2.5 - 5 mg

5 -30 mg **

Levomepromazine

Especially if features of paranoia or psychosis are present. Also useful as an antiemetic. Very sedative at higher doses. Smaller doses in elderly

12.5 -25 mg

12.5 -25 mg

12.5 -75 **mg

Haloperidol

Especially if features of paranoia or psychosis are present. Also useful as an antiemetic. Smaller doses in the elderly

1.5 - 2.5 mg

1.5 - 2.5 mg

2.5 - 5mg

* Midazolam may cause disinhibition and paradoxical agitation, particularly at high doses.

** Start at lowest dose in the range especially in frail elderly patients; review dose every 24 hours and increase if necessary by 30% -50% according to additional as required doses. Higher doses than this are occasionally necessary - seek Specialist Palliative Care Team advice.

  • Patients who are dying with severe agitation may be very resistant to the effects of sedatives and may need repeat doses at 30 -60 minute intervals until settled
  • Occasionally the combined administration of an anti-psychotic and benzodiazepine is required
  • For patients requiring rapidly escalating doses of sedatives, contact the Specialist Palliative Care Team for advice

NB: benzodiazepines may occasionally have a paradoxical alerting effect and worsen symptoms. Early and frequent review is essential.

Occasionally the combination of an antipsychotic and benzodiazepine is required (seek specialist advice), e.g. levomepromazine 50mg + midazolam 30mg/24hr(1)

The respective summary of product characteristics must be consulted before prescribing any of the drugs detailed.

Reference:

  1. West Midlands Palliative Care Physicians (2003). Palliative care - guidelines for the use of drugs in symptoms control.
  2. West Midlands Palliative Care Physicians (2012). Palliative care - guidelines for the use of drugs in symptoms control.

Related pages

Create an account to add page annotations

Create a free account

Annotations allow you to add information to this page that would be handy to have on hand during a consultation. E.g. a website or number. This information will always show when you visit this page.

The content herein is provided for informational purposes and does not replace the need to apply professional clinical judgement when diagnosing or treating any medical condition. A licensed medical practitioner should be consulted for diagnosis and treatment of any and all medical conditions.

Connect

Copyright 2024 Oxbridge Solutions Limited, a subsidiary of OmniaMed Communications Limited. All rights reserved. Any distribution or duplication of the information contained herein is strictly prohibited. Oxbridge Solutions receives funding from advertising but maintains editorial independence.