A 2025 review is raising important questions about standard end-of-life care practices, finding that much of the evidence supporting routine interventions for delirium, terminal bleeding, and noisy respiratory secretions is weak — or in some cases, contradicted by newer data.

For terminal delirium, the review recommends haloperidol or levomepromazine as first-line agents, but a randomized trial found lower delirium scores with placebo than with risperidone or haloperidol — and shorter survival in the haloperidol group. For terminal bleeding, the standard advice to prepare parenteral midazolam in advance is questioned, since patients can lose consciousness in under a minute, leaving little time for the drug to work. The review's clearest guidance: stay with the patient and remain calm. For noisy respiratory secretions — present in up to 92% of expected deaths — a Cochrane review found no pharmacologic or non-pharmacologic intervention outperformed placebo.

Key Takeaways:

• Screen for delirium using validated tools (4AT or Nursing Delirium Screening Scale) and treat reversible causes before reaching for medications
• In terminal bleeding, physical presence and calm may matter more than rescue medication
• Antimuscarinic agents for secretions are widely used but lack strong evidence; choice should be guided by patient comorbidities and drug interactions

Why it matters: These findings encourage clinicians to reconsider automatic pharmacologic intervention in dying patients, and instead center care on comfort, communication, and early palliative involvement — particularly when the evidence for standard interventions is limited.