Severe behavioural and psychological symptoms of dementia (BPSD), associated with risk to self and others, often necessitate urgent intervention. Despite well-documented risks, antipsychotics remain frequently prescribed for these symptoms, reflecting complex influences on prescribing decisions. In this presentation, we critically explore these challenging contexts, including difficulties in defining severe BPSD, conflations and limitations of current evidence and clinical guidelines, and legal and policy frameworks that shape care. We advocate the adoption of alternative paradigms, notably palliative approaches, to address the considerable distress associated with severe BPSD, while remaining attentive to sociological critiques. The broader aim of this presentation is to stimulate discussion on the development of more humane and holistic models of care in this challenging area of older adult psychiatry.