RPD107 - An interprofessional approach to improving management of agitation in an inpatient palliative care unit

Key Message : Implementation of standard assessment and treatment of agitation in an inpatient palliative care unit is feasible, and was associated with decreased deep sedation, increased awake and calm patients, and increased agitation.

Abstract:

Background: Agitated delirium is common at the end of life, and is both distressing and a safety risk to patients, families, and care teams. Despite the frequency and seriousness of end of life agitation, data on the best way to manage it remains sparse.(1,2)

Objective: To improve relief of agitation in an inpatient palliative care unit through implementation of a standard approach to assessment of, and medication use for agitation.

Methods:
Setting: An 8-bed inpatient palliative care unit (IPU) within a rural academic medical center. Approach: We implemented routine assessment with RASS-PAL in January 2025.(3) An interprofessional workgroup iteratively developed an evidence-based treatment algorithm for agitation, beginning with haloperidol and outlining addition of benzodiazepines and phenobarbital, with guidance given for dose escalation. The treatment algorithm was implemented in May 2025.
Analysis: We defined the pre-intervention period as the three months before implementation, and the post-intervention period as the three months after, with the month of implementation excluded as a “wash-in” period. Primary outcomes were incidence of moderate-deep sedation (RASS-PAL -3 or lower), awake/calm (RASS-PAL 0), and agitation (RASS-PAL +2 or higher) and changes in rates of medication usage.

Results: Over the study period of February-August 2025, 256 patients were admitted to the IPU, 247 (96%) of whom had RASS-PAL assessed. One hundred twenty-nine patients (50%) had agitation overall. Compared to pre-intervention, there was lower incidence of moderate-deep sedation (43% to 29%), increased incidence of awake/calm (14% to 20%), and increased agitation (44% to 52%) post-intervention. Scheduled haloperidol use increased from 21% of patients in the pre-intervention period to 30% post-intervention. Use of any scheduled benzodiazepine increased from 90% pre-intervention to 97% post-intervention.

Implications: We anticipate further revisions to our algorithm with additional data from this ongoing QI work, with planned analysis of patient-level data and patient/family-reported outcomes measures.

References: 1. Hui D, De La Rosa A, Tsai J-S, et al. Proportional sedation for persistent agitated delirium in palliative care: A randomized clinical trial: A randomized clinical trial. JAMA Oncol. 2025;11: 1031–1043.
2. Bush SH, Leonard MM, Agar M, et al. End-of-life delirium: issues regarding recognition, optimal management, and the role of sedation in the dying phase. J Pain Symptom Manage. 2014;48: 215–230.
3. Bush SH, Grassau PA, Yarmo MN, et al. The Richmond Agitation-Sedation Scale modified for palliative care inpatients (RASS-PAL): a pilot study exploring validity and feasibility in clinical practice. BMC Palliat Care. 2014;13: 17.