Terminal agitation is taught as a frequently encountered and expected condition at the end of life, possibly leading to a reversible cause of delirium not being identified with subsequent and unnecessary drug dose escalation. Opioids and sedative medications are recognised as potentially reversible causes of delirium. But what if we, in all the caring we do for our patients, often assume that the building distress is due to pain and continue to increase the opioid dose—could we possibly be contributing to end-of-life delirium?

Over the past 10 years, there has been a significant change in prescribing practice within St Cuthbert’s Hospice, Durham, as well as in the management of hyperactive delirium at the end of life. The clinical team at the …