Agitation and delirium are commonly encountered symptoms in palliative care. Based on the clinical features, delirium may present in the hypoactive, hyperactive and mixed forms. By reason of the prevalence, the significant distress and symptom burden, as well as the possibility of reversibility, it is vital that the clinician be vigilant in identifying and treating delirium and its symptoms. This article describes how delirium may present, the clinical features, aetiologies and the methods to screen and diagnose delirium. When managing a delirious patient in the palliative care setting, it is necessary to contextualise any investigation and intervention in terms of the disease condition and trajectory, the level of distress and the care preferences and goals of the patient and family. Non-pharmacological management should always be in place though pharmacological treatments also have a definite role in the relief of distressing symptoms of agitation and delirium. Support and education for the patient, family and care providers are integral and continuous aspects of care for the agitated or delirious terminally ill patient.