Terminal Agitation in an Imminently Dying Patient with Renal Failure

At the end of life, agitation is a syndrome, not a diagnosis. I would look for reversible contributors: urinary retention, fecal impaction, pain, dyspnea, fever, dehydration, hypoglycemia, hypercalcemia, and medication effects. This man's myoclonus and renal failure raise opioid neurotoxicity; lorazepam can also cause paradoxical agitation and is a poor choice in delirium. Terminal delirium often presents with restlessness, picking, and moaning, but pain can produce similar behavior. I would use the family's knowledge of his baseline and observe whether the behavior changes with positioning, a gentle touch, or a rescue opioid. Moaning does not automatically mean pain; it can be respiratory, existential, or neurologic. I would examine for a distended bladder, check a fingerstick glucose and calcium if feasible, and review all medications. If he is actively dying, extensive testing may be burdensome, so the workup should be targeted. The key is to avoid treating every moan with more morphine, which could worsen myoclonus and hasten death without relieving suffering.

First, stop the morphine and lorazepam, both of which may be contributing. Rotate to fentanyl, which is safer in renal failure, using a low starting dose and frequent reassessment. For delirium, haloperidol 0.5–1 mg SC or IV every 6–8 hours is first-line; if he has Parkinson disease or Lewy body dementia, use quetiapine or clozapine instead. Benzodiazepines are generally avoided in delirium unless the agitation is dangerous or the cause is alcohol or benzodiazepine withdrawal; midazolam can be used for terminal agitation when antipsychotics fail. If he remains distressed despite these measures, palliative sedation with midazolam, titrated to comfort, is ethically permissible when the intent is symptom relief and the dose is proportional. I would discuss this explicitly with the family, explain that the intent is not to hasten death, and document consent from the surrogate. I would also stop unnecessary medications and consider whether artificial hydration is contributing to secretions or dyspnea. Nonpharmacologic care-quiet room, familiar voices, positioning-matters as much as drugs.

I would bring the family together at the bedside and start by naming the conflict without judgment: 'You both love him, and you are describing different ways of protecting him.' I would ask each daughter what she fears most and what she believes he would want. I would explain the dying process-mottling, noisy breathing, decreased urine output-and that he is likely not experiencing hunger or thirst in the way we do. I would address the request for 'everything': in an inpatient hospice, CPR is not provided, and in his condition it would not restore him to a meaningful life. I would explain that comfort care is active care, not giving up. If one daughter demands CPR, I would explore whether she feels guilt or pressure from other family members, and I would offer chaplain and social work support. I would identify the surrogate decision-maker and, if there is no advance directive, follow the state's hierarchy. If the conflict remains, I would involve the ethics committee or the hospice medical director. Documentation should include the family meeting, who said what, the medical facts, the ethical reasoning, and the plan for escalation.