Background: Sedation at the end of life is used to relieve distressing symptoms including agitation and delirium. Standard caremay include infused benzodiazepines or antipsychotics. These agents often result in deep sedation with loss of interaction withloved ones, which may be distressing. Objective: The DREAMS (Dexmedetomidine for the Reduction of End-of-life Agitation and for optiMised Sedation) trialaimed to compare the sedative and antidelirium effects of the alpha-2 agonist dexmedetomidine, a novel palliative care sedative,compared with midazolam, a benzodiazepine when administered by subcutaneous infusion at the end of life, with doses of bothagents targeting lighter, or potentially interactive sedation. Methods: Participants were recruited from adult inpatients admitted for end-of-life care under a palliative care team in regionalNew South Wales, Australia. Inclusion criteria included patients older than 18 years, with a preference for lighter sedation at theend of life. Exclusion criteria included severe cardiac dysfunction (contraindication to dexmedetomidine). Participants consentedand were placed on a treatment-pending list. Upon experiencing terminal deterioration, patients were randomized to either arm1 (dexmedetomidine) or arm 2 (midazolam) as their treatment arm. These treatments were administered by continuous subcutaneousinfusion. The level of consciousness and agitation of the patients were measured by the Richmond Agitation-SedationScale-Palliative version and the Memorial Delirium Assessment Score. Richmond Agitation-Sedation Scale-Palliative versionassessments were performed by both nursing and medical staff, while Memorial Delirium Assessment Score assessments werecarried out by medical staff only. Families and patients were asked to complete, as able, a patient comfort assessment form, togauge perceptions of distress. Data were collected and matched with the breakthrough medication doses administered, along withqualitative comments in the medical record. In addition, the study tracked symptoms and patient functional status that wererecorded as part of the Palliative Care Outcomes Collaborative, a national tracking project for monitoring symptom outcomes inpalliative care. Results: The DREAMS trial was funded in May 2020, approved by the ethics committee in November 2020, and startedrecruiting participants in May 2021. Data collection commenced in May 2021 and is anticipated to continue until December 2024.Publication of results is anticipated from 2024 to 2026. Conclusions: The evidence base for sedative dosing in palliative care for distress and agitation is not robust, with standard carebased primarily on clinical experience and not robust scientific evidence. This study is important because it will compare astandard and a novel sedative used in end-of-life treatment. By assessing the potential efficacy and benefits of both, it seeks tooptimize the quality of dying by providing targeted sedation that can improve the communication between dying patients andtheir loved ones
