Nicotine withdrawal: An under-recognised cause of terminal restlessness

Dr Shamila Ginige, Medical Resident, Monash Health, Melbourne, Victoria, Australia explains the background to her longer article published in the May/June edition of the European Journal of Palliative Care. Shamila describes how nicotine withdrawal is an under-recognised and easily reversible contributor to agitation in the final days of life.

Dr Shamila Ginige

Dr Shamila Ginige

I wrote this review article during my internship at McCulloch House, inpatient palliative care unit – my first real experience of palliative medicine. I spent three months learning not only about common symptoms and medications, but also about the multidisciplinary approach to managing patients with life-limiting illness. I also learnt how to have an open discussion with people, during this difficult time in their lives.

The contrast with acute medicine highlighted the importance of minimal invasiveness and comfort for patients, when investigating and managing their symptoms. Once patients have come to a hospice, they have already been through countless blood tests, scans and procedures. It’s no wonder that a questionnaire in 2008 found that more than 40% of specialists would not do any investigations for delirium in the final days of life (1).

McCulloch House is a level three-inpatient palliative care unit associated with Monash Health, located in Melbourne. There were a number of patients I saw who were restless or agitated in the final days of their life. In these cases, it was evident that it was quite distressing for patients and their families.

Biopsychosocial causes of terminal restlessness need to be addressed both before and during the active dying process. During my rotation, I learnt about the common reversible causes – does the patient have constipation? Are they in urinary retention? How well is pain controlled? Are they emotionally distressed?

While conducting a literature review on nicotine withdrawal as a cause of terminal restlessness, I found that there was a significant overlap of symptoms from nicotine withdrawal and a delirium. In the eight patients looked at in these studies, a nicotine patch helped to alleviate symptoms of terminal restlessness.

Nicotine is very addictive. Smokers commonly feel anxious and agitated without their usual number of cigarettes, why should the final days of life be any different?


  1. Agar M, Currow D, Plummer J, Chye R, Draper B. Differing management of people with advanced cancer and delirium by four sub-specialties. Palliat Med. 2008 Jun; 22(5): 633-40.

EJPC23.3coverRead the full article in the European Journal of Palliative Care
This post relates to a longer article, ‘Nicotine withdrawal: an under-recognised cause of terminal restlessness’ by Shamila Ginige, is published in the May/June 2016 edition of the European Journal of Palliative Care (vol. 23.3).

If you have a web-based subscription to the journal you’ll be able to download this issue, plus all articles in the journal archive. You can also browse the archive and download articles by taking a 10-minute or 30-minute subscription. Members of the EAPC receive discounted subscription rates to the journal – click here to subscribe online.

This entry was posted in EAPC-LINKED JOURNALS, European Journal of Palliative Care, RESEARCH, SYMPTOM CONTROL and tagged . Bookmark the permalink.

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