Delirium, severe bleeding, and noisy breathing can make the final days of life distressing for patients, their families, and care teams. Although these guidelines address many of these situations, a review published in 2025 found that much of the evidence supporting the established recommendations is weak. Recent data have prompted fundamental questions regarding standard practices.

Typical features of delirium include memory disturbances, disorganised thinking, and reversal of the sleep-wake cycle. Hyperactive delirium can cause restlessness, agitation, and hallucinations, whereas hypoactive delirium is characterised by lethargy and withdrawal. Patients may also exhibit features of both patterns. Severe hyperactive delirium can manifest as terminal agitation in the final days of life; however, agitation alone does not necessarily indicate delirium. Dyspnoea, existential distress, and rapid clinical deterioration can lead to restlessness and agitation.

The first step is to establish a diagnosis. The review identified two rapid, objective screening tools: the 4AT, a four-item delirium screening tool validated in hospice inpatient units, and the Nursing Delirium Screening Scale, a five-item observational tool used by nursing staff to screen hospitalised patients for delirium. Clinicians should then assess potential triggers, including pain, constipation, urinary retention, infection, opioid toxicity, hypercalcaemia, intracranial causes, and drug accumulation. Several factors may contribute simultaneously. For example, hypercalcaemia can cause dehydration and renal dysfunction, leading to the accumulation of renally excreted medications, such as morphine, and worsening delirium.

Not every potential cause warrants extensive investigation at the end of life. Decisions should reflect patients’ wishes and whether identifying the cause would lead to meaningful treatment. Brain CT or lumbar puncture, for example, is appropriate only when the results can guide treatment that is likely to provide sustained benefits in the patient’s clinical circumstances.

Use Medication Cautiously for Irreversible Delirium

Irreversible delirium occurs when no treatable cause can be identified, treatment has failed, or treatment limits have been reached. Communication, reorientation, and reassurance may be helpful, although these approaches may not be feasible for patients who are actively dying. Supporting family members is also important because confusion and agitation can be distressing.

According to the authors of the review, medications should initially be administered only as needed. If this approach does not provide adequate symptom control, continuous subcutaneous administration using an infusion pump should be considered. The review recommends haloperidol and levomepromazine as the preferred agents. Midazolam may be considered when rapid symptom control is needed, but it should be used cautiously because it can cause paradoxical agitation. The practical approach is to start with a low dose, increase it gradually, and involve palliative care specialists early.

However, evidence supporting pharmacologic treatment is uncertain. A randomised, double-blind trial reported lower delirium scores with placebo than with risperidone or haloperidol. Overall survival was also shorter in the haloperidol group. These findings favour supportive measures and targeted treatment of precipitating factors, although they have had a limited influence on prescribing practices.

Persistent, uncontrolled, and severe delirium requires urgent specialist palliative care. Continuous sedation may be necessary in particularly severe cases.

Terminal Bleeding: Presence May Matter More Than Rescue Medication

Terminal bleeding can leave little time for intervention. The term refers to severe arterial bleeding that can be fatal within a few minutes. Advanced head and neck cancers located close to the major arteries are of particular concern, especially when previous radiotherapy increases tissue fragility. Minor bleeding may occur but is not always present. Similar bleeding has been described in patients with pulmonary, upper gastrointestinal, and uterine tumours.

Standard recommendations include identifying at-risk patients in advance and preparing emergency medications, particularly parenteral midazolam. Dark towels can be used to cover visible blood and reduce distress. However, these recommendations have little support from prospective studies and rely largely on consensus statements and qualitative reports.

Clinical experience has raised questions regarding the effectiveness of this approach in clinical practice. Terminal bleeding is difficult to predict reliably and can progress rapidly. Patients may lose consciousness in less than a minute, leaving little time for intravenous midazolam to be effective. Subcutaneous administration results in an even slower onset of action.

Staff may also leave the patient alone while retrieving medication. On the basis of these experiences, the review authors emphasised a clear priority: stay with the patient and remain calm. If another person is available, they can summon help and prepare the necessary equipment and medications. Visible bleeding sites can be compressed, and dark towels can be used to conceal blood. For bleeding from the mouth, positioning the patient on their side with the bleeding side facing downward may reduce the risk for aspiration and choking.

Preparing for possible terminal bleeding presents additional challenges for patients who wish to die at home. Discussing potential risks is important; however, such conversations can cause considerable anxiety. The authors recommend gently assessing the amount of information the patient wants and avoiding rushed discussion.

Previous bleeding episodes and evidence of tumour extension close to an artery can inform risk assessment. Clinicians must balance the benefits of preparation with the possibility of causing unnecessary distress by discussing uncommon events in detail.

Noisy Respiratory Secretions: Often More Distressing for Families

Secretions in the upper airway can produce loud breathing sounds during the final days of life. This symptom has been reported in up to 92% of expected deaths. It occurs mainly when reduced consciousness prevents patients from swallowing or coughing up secretions and is therefore considered a sign of approaching death. Deeply unconscious patients are rarely distressed by these sounds, but family members may interpret them as signs of “choking” or “drowning.”

The first step is to educate and reassure family members. Changing the patient’s position can also be helpful. If these measures are insufficient, clinicians may consider a trial of parenteral antimuscarinic medication, such as hyoscine butylbromide, hyoscine hydrobromide, or glycopyrronium bromide.

The authors do not specify a preferred antimuscarinic agent. The choice should consider the patient’s comorbidities, the risk for adverse effects, and other medications. If a single dose is effective, continuous administration should be considered. However, these medications do not clear secretions that have already accumulated.

Potential adverse effects include dry mouth, urinary retention, and constipation, which may contribute to confusion. Hyoscine hydrobromide can also cross the blood-brain barrier and cause confusion.

Despite their widespread use, evidence supporting these interventions remains weak. A Cochrane review found no evidence that any pharmacologic or nonpharmacologic intervention was more effective than placebo. The authors suggest that the desire to provide relief when death is imminent may help explain why antimuscarinics continue to be used despite limited evidence of benefit.

This story was translated from Univadis Germany, part of the Medscape Professional Network.