19/11/2025
In both opioid toxicity and natural dying,
➡️ the patient has typically become very sleepy but it is not yet clear why…
➡️ they can be confused, agitated and hallucinating
➡️ breathing can become slower and more shallow, and oxygenation may fall
So, how can we tell?
First thing to say - this can be difficult!
📋 Go back to basics - find out the history, what has happened leading up to this, check medications and recent investigations. This, as well as observation and examination will be key.
Keep your mind open. The differential should still include infection, trauma, neurological event (stroke, seizure), metabolic disturbance, toxins, drugs etc. 🔤…Don’t Ever Forget Glucose!
🔆Opioid-toxicity🔆
⭐️ Sleepiness develops in the context of a recent increase in opioid dose, or something acute that has changed the body’s response to opioids, such as chemo/radiotherapy, dehydration, infection, or impairment of kidney or liver function.
You might see:
🔴Visual hallucinations - patients describe moving patterns, birds, animals, or people; difficulty judging position of items in space; blurring of dreams into lived reality.
🔴 Myoclonic jerks - involuntary jerking of muscles, every few seconds, seen mostly in forearms/hands, as well as calves and feet.
❓Pinpoint pupils - only helpful if other signs are there, not diagnostic on their own. NB: Many older people have small pupils (senile miosis)
💠 Natural dying 💠
⭐️ Sleepiness usually develops in the context of someone who has been deteriorating, eating and drinking less, moving less.
You might see:
⚪️ Detached state - sometimes people become more withdrawn and less interested in things they usually care about, including loved ones.
⚪️ Terminal delirium - confusion, agitation, hallucinations. Repeatedly doing things without purpose: getting in and out of bed, pulling at bedclothes.
⚪️Death-bed visions - often seen in patients who are otherwise compos mentis. They see loved ones who have died, with no other perceptual changes.
⚪️ Sudden burst of energy - the person suddenly wakes, eats, spends time talking with family, before deteriorating again.
❓Twitching - there can be twitching/jerking of muscles but usually only seen with end-stage kidney or liver failure.
🙋🏻♀️❓What have you seen in similar situations? Have you been able to find out the cause?
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I refer here to opioid toxicity using the umbrella term, but if you would like to know more about the specifics of Opioid-induced respiratory depression (OIRD) or Opioid-induced neurotoxicity have a look at these links👇
https://lnkd.in/gDr632KD
https://lnkd.in/gN-cJgPM
https://lnkd.in/gVNTDXPJ
https://lnkd.in/gZ_SuBKG
https://lnkd.in/g22d6DEs
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Hi 👋🏻 I’m Katie Weatherstone, a Palliative Medicine consultant in New Zealand
Follow me on LinkedIn for topics related to palliative care and the experiences of patients with advanced illnesses, as well as those caring for them.
