Terminal care: management of anxiety and emesis - clinical fact sheet and MCQ

Overview

General practitioners play a key role in delivering terminal care in the home. For uncomplicated, community-based palliative care patients, four medicines are recommended to manage common emergent terminal symptoms to improve patient comfort and reduce carer stress. These are morphine for pain and dyspnoea, hyoscine for respiratory secretions (see our previous FastTrack), clonazepam for agitation, anxiety, terminal restlessness, and seizure, and haloperidol for delirium, nausea/vomiting, terminal restlessness, and refractory distress.

Detailed information about these core medicines in terminal care can be found in the free palliMEDs app as well as in this consensus-based list.

Additionally, the caring@home Prompts for End-of-Life (PELP) Planning tool provides a recommended framework for a terminal care management plan that considers symptom control, anticipatory prescribing, and other issues.

Anxiety and emesis in terminal care 

About two-thirds of patients referred to palliative care services experience clinically-relevant anxiety, and up to 70% of people with advanced cancer report nausea and/or vomiting at some stage during their illness. These symptoms are common, distressing, and often co-exist, requiring thoughtful and individualised management.

Anxiety at the end of life may be driven by existential concerns, psychosocial stressors, or progressive physical deterioration. 

Nausea and emesis may result from gastrointestinal dysfunction, irritation, or obstruction, opioid use, metabolic disturbance, anxiety or pain, or intracranial disorders. Both symptoms can contribute to refractory distress and reduced quality of life if not managed effectively.

Clonazepam in terminal care

Agitation

Clonazepam, a long-acting benzodiazepine, is effective in managing terminal agitation when non-pharmacological strategies are insufficient. It is particularly useful in people with anxiety-driven restlessness or where short-acting agents require frequent redosing.

Anticipatory prescribing: in patients who are  benzodiazepine-naive, consider 0.2-0.5 mg sublingually or subcutaneously, every two hours as required.

Regular prescribing: may be considered if agitation is persistent or more than three PRN doses are required within 24 hours:

• 0.2-0.5 mg sublingually or subcutaneously every 12 hours

OR

• 0.5-1 mg over 24 hours by continuous subcutaneous infusion

• an additional 0.2-0.5 mg 2-hourly may be administered subcutaneously or sublingually for breakthrough distress

Monitor for effectiveness.
If refractory distress, seek specialist advice; palliative sedation may be necessary for adequate symptom relief.

Distressing breathlessness

Benzodiazepines such as clonazepam may alleviate the anxiety component of breathlessness when opioids alone are insufficient. It is especially helpful in patients with persistent dyspnoea accompanied by panic or emotional distress. 

Anticipatory prescribing: in patients not already taking benzodiazepines, consider 0.2-0.5 mg sublingually or subcutaneously every two hours as required.

Regular prescribing: may be considered for persistent or worsening distressing breathlessness or if more than three PRN doses are required within 24 hours: 

• 0.2-0.5 mg sublingually or subcutaneously every 12 hours

OR

• 0.5-1 mg over 24 hours by continuous subcutaneous infusion
• an additional 0.2-0.5 mg 2-hourly may be administered subcutaneously or sublingually for breakthrough symptoms

Seizures

In palliative settings, clonazepam is a practical option for seizure management in people who are unable to take regular oral antiepileptics. It may be used acutely for seizure control. Clonazepam is also considered when midazolam is unavailable for long-term use or when financial considerations are important.

Acute management if seizure activity is not self-limiting: 1 mg intravenously, subcutaneously, or sublingually every 10 minutes as required.

Multifocal myoclonus may be associated with adjustments to opioid use: 0.5-1 mg orally, subcutaneously, or sublingually, one to two times a day for symptom management until the new opioid regime becomes effective.

Haloperidol in terminal care

Agitation

Haloperidol is a first-generation antipsychotic and is used in the management of agitation in terminal care, especially when associated with delirium. It is a preferred agent where sedation needs to be minimised, and is suitable for use via a syringe driver for continuous symptom control.

Anticipatory prescribing: for patients not already taking haloperidol, anti-emetics, or other antipsychotics, use 0.5-1 mg subcutaneously every four hours as required .

Regular prescribing: may be considered for persistent agitation or if more than three doses are required within 24 hours: 

• 0.5-1 mg subcutaneously every 12 hours and 0.5-1 mg 4-hourly as required

OR

• 1-2.5 mg over 24 hours  by continuous subcutaneous infusion and 0.5-1 mg subcutaneously every four hours as required

Nausea and vomiting

In palliative care, haloperidol is used off-licence for nausea. It can be particularly useful as a first-line antiemetic for certain causes of nausea, such as those related to opioids, uraemia, or toxins. It can be particularly useful in malignant bowel obstruction, where prokinetics like metoclopramide are contraindicated. 

Anticipatory prescribing: for intermittent symptoms in patients not already on haloperidol, other antipsychotics, or antiemetics, use 0.5-1 mg subcutaneously every four hours as required.

Regular prescribing: for persistent nausea and vomiting or if more than three PRN doses  are required within 24 hours: 

• 0.5-1 mg subcutaneously every 12 hours and 0.5-1.0mg 4-hourly as required

OR

• 1-2.5 mg over 24 hours by continuous subcutaneous infusion and 0.5-1 mg subcutaneously every four hours as required

The usual maximum dose of haloperidol is 5 mg within 24 hours.

Key considerations for general practice

• Use non-pharmacological strategies as an adjunct alongside pharmacotherapy
  • anxiety: provide emotional support, gentle touch 
  • distressing breathlessness, particularly if exacerbated by anxiety or panic: positioning, open windows, fan therapy
  • nausea/emesis: do not try and force people to eat. If hungry, try small and frequent meals. Avoid sensory triggers
• When using clonazepam or haloperidol start at the lowest effective dose
• Reassess regularly to ensure alignment with patient goals
  
  

Indications for specialist referral

• Refractory anxiety, restlessness, or emesis despite optimal management
• Complex symptom aetiology (eg, suspected bowel obstruction, intracranial pathology)
• Severe psychiatric comorbidity or risk of harm
• Need for parenteral or continuous medicine infusions not available in the primary care setting

References

1. Therapeutic Guidelines. Anxiety and associated disorders in palliative care. 2024. Available at: https://app.tg.org.au/viewTopic?etgAccess=true&guidelinePage=Palliative%20Care&topicfile=palliative-care-overview&guidelinename=auto&sectionId=c_PCG_Anxiety-and-associated-disorders-in-palliative-care_topic_4#c_PCG_Anxiety-and-associated-disorders-in-palliative-care_topic_4. (last accessed July 2025).
2. Glare P, Miller J, Nikolova T, Tickoo R. Treating nausea and vomiting in palliative care: a review. Clin Interv Aging. 2011;6:243-59. 
3. Gurgenci T, Podbury B, O’Leary C, Good P. Palliative management of nausea and vomiting in advanced cancer. AJGP. 2024;52(11):S33-S36.
4. CareSearch. Nausea. 2024. Available at:https://www.caresearch.com.au/Evidence/Clinical-Evidence-Summaries/Nausea. (last accessed July 2025).
5. Tranung, M., Solheim, T.S., Løhre, E.T. et al. Emergency palliative cancer care: anxiety and midazolam. BMC Palliat Care.2025;24: 64.
6. CareSearch. Anxiety. 2024. Available at: https://www.caresearch.com.au/Evidence/Clinical-Evidence-Summaries/Anxiety. (last accessed July 2025).
7. BpacNZ. Managing nausea and vomiting in the last days of life. 2023. Available at: https://bpac.org.nz/2023/last-days-of-life/docs/ldol-nausea.pdf. (last accessed September 2025). 

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