As an experienced , I understand how difficult it can be to distinguish between delirium and terminal . Both conditions can cause significant distress for the patient and their loved ones, and it's crucial for nurses to be able to tell the difference between the two to provide the best possible care. In this article, I will share my knowledge and experience to help new hospice nurses understand the differences between delirium and terminal along with ways to rule out delirium.

What is Delirium?

Delirium is a sudden change in mental status that can occur in patients who are seriously ill, especially those who are elderly or have underlying health conditions. It is characterized by a disturbance in attention and awareness, as well as changes in thinking, perception, and behavior. Common symptoms of delirium include:

Delirium can be caused by a variety of factors, including constipation, urine retention, , infections, dehydration, and metabolic imbalances. It's important for nurses to be aware of the risk factors for delirium and to monitor patients closely for any signs or symptoms.

What is Terminal Restlessness?

Terminal restlessness is a type of delirium that can occur in patients who are in the final stages of a terminal illness. It is characterized by , , and restlessness, as well as cognitive impairment and changes in mood. Common symptoms of terminal restlessness include:

  • Pacing or fidgeting
  • Agitation or aggression
  • Confusion or disorientation
  • or
  • Rapid mood swings

Terminal restlessness is irreversible and is a common part of the natural dying process that can be managed to reduce distress to the patient and their loved ones.

How to Tell the Difference Between Delirium and Terminal Restlessness

While delirium and terminal restlessness share some common symptoms, there are a few key differences that can help nurses distinguish between the two:

  • Timing: Delirium can occur at any time during a patient's illness, while terminal restlessness typically occurs in the final stages of a terminal illness. This means that delirium can happen early or late in the disease process, and it can come and go. Terminal restlessness, on the other hand, usually happens when the patient is close to dying, and it can last until the end of life. Knowing the timing of these conditions can help nurses identify the possible causes and treatments for each patient.
  • Cause: Delirium can be caused by a variety of factors, while terminal restlessness is usually caused by the underlying terminal illness.
  • Symptoms: While both delirium and terminal restlessness can cause confusion and agitation, terminal restlessness is typically more severe and may be accompanied by other symptoms such as hallucinations or delusions.

As a , it's important to approach each patient as an individual and to consider their unique medical history and symptoms when making a diagnosis. If you suspect that a patient is experiencing delirium or terminal restlessness, it's important to consult with the interdisciplinary team and to develop a plan of care that addresses the patient's physical, emotional, and spiritual needs.

Ruling out Delirium

Consider the following reversible causes and evaluate if the patient is having any of these issues and then address appropriately:

Pain: Does the patient have unmanaged pain? How is the patient's pain currently being managed? What changes can take place to better manage the patient's pain?

Constipation: When was the patient's last bowel movement? If more than three days or unknown, treat for constipation unless contra-indicated.

Urine retention: If the patient does not have end-stage renal disease where they are anuric, are they urinating? Palpate the patient's bladder, obtain an order for a bladder scan or straight Cath with education that a chronic foley may need to be placed.

Infection: Assess for UTI, respiratory infection, GI infection, sepsis. If infection is found, work with the provider being clear on communicating known allergies and following any pre-existing orders to treat or not treat infection (some states like Pennsylvania allow the POA/family to make that determination). Keep in mind sepsis may not be reversible if caught late.

Recently broken bones or fractures: assess for internal bleeding remembering blood is a powerful laxative; assess for blood in the stool as well as any coffee ground emesis. Please keep in mind that if there is internal bleeding, like sepsis which is caught too late, typical delirium may turn into terminal restlessness that leads to death.

Dehydration: If the patient is awake and alert with an intact gag reflex, are they hydrated enough? If not, encourage fluids.

Medications: was there recent medication changes — new meds, changed doses, or discontinuation of medications where it may be possible the meds were stopped without proper titration. Consider reviewing all the medications the patient is taking with a hospice pharmacist to rule out medication-induced delirium.

Metabolic imbalances: Electrolyte imbalances and metabolic disorders such as liver or kidney failure can cause delirium. Treating the underlying condition can help alleviate symptoms. Remember that if the patient has had frequent loose stools or vomiting with emesis, they will have an electrolyte imbalance as well as dehydration.

Consider increasing your visit frequency while you are ruling out delirium; consider your resources such as your fellow team members, medical director, hospice pharmacists as well as the patient's attending provider.

Include the family as they know their loved one best and can help share critical information such as if the patient suffered delirium in the past and what helped or didn't help as well as asking them to paint a picture of what that looked like in the past.

Communication and Coordination

Delirium and terminal restlessness are distressing to the patient, the caregivers, and the family. Be diligent in communicating your findings to the caregivers and family. Coordinate with the IDG team and all those involved in the care of the patient so that everyone is on the same page.


Terminal restlessness typically occurs within the transitioning stage of the dying process; and usually indicates there are only hours to days for the patient to live (keep in mind days can become a week or two). Delirium can occur anywhere within the patient's journey towards the end of life; and can sometimes be confused with terminal restlessness. It is important for hospice staff to work towards ruling out delirium — which is treatable — to provide the best of care with comfort in mind.


What is Delirium (PDF)

Reversible delirium in terminally ill patients

A Change in Behavior: Delirium, Terminal Restlessness, or Dementia, A Pragmatic Clinical Guide

The Importance of Caregiver Journaling

Reporting Changes of Condition to Hospice

Eldercare Locator: a nationwide service that connects older Americans and their caregivers with trustworthy local support resources

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Providing Comfort During the Last Days of Life with Barbara Karnes RN (YouTube Video)

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