Dr. Finucane correctly points out that few data are available to guide the management of delirium in patients near the end of life. We strongly agree that research to guide the treatment of delirium is urgently needed, and this fact was a major area of emphasis in our article. However, in the absence of evidence from robust clinical trials, our recommendations are based on evidence provided by the medical literature, consensus of expert opinion, and our clinical experience in the care of patients at the end of life. In fact, the American College of Physicians–American Society of Internal Medicine End-of-Life Care Consensus Panel was convened to synthesize the best available evidence to guide end-of-life care. It was on the basis of the best available evidence that our recommendations were formulated.

We also agree with Dr. Finucane about the limitations of the clinical trial cited (1). However, the recommendation supporting haloperidol was based not on this clinical trial alone but also on the consensus of palliative care clinicians as well as our own experience. Benzodiazepines are not recommended as a first-line treatment in the management of delirium near the end of life, since they are likely to produce sedation that many patients and families find unacceptable. When sedation is desirable, we prefer chlorpromazine, which produces sedation with less risk for respiratory depression. In general, however, we maintain that haloperidol offers the best balance of effectiveness and toxicity. We agree with Dr. Finucane that there is no current evidence to support the use of atypical antipsychotic agents. We also agree that treatment goals should always be set and that modification of the treatment regimen may be required to meet these goals.

With regard to the biological plausibility of the effectiveness of haloperidol for treatment of delirium, several lines of evidence have suggested that imbalance or hyperactivity in the dopaminergic system may contribute to delirium (2, 3). Thus, a dopamine-blocking agent such as haloperidol may well demonstrate beneficial effects. The benefits of haloperidol for the hallucinations, delusions, paranoia, and agitation that may accompany delirium are certainly in line with its well-documented effectiveness for similar symptoms of dementia as well as schizophrenia. Therefore, we continue to support and recommend haloperidol as first-line treatment for delirium at the end of life. We hope that future studies will be undertaken to provide a solid evidence base to guide end-of-life care.