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Palliative Management of Delirium

Palliative Management of Delirium

Discussion 4: Palliative Management of Delirium

An 81-year-old female patient diagnosed with metastatic lung cancer has experience delirium, which presents one of the common neurological complications at the end of life. The first step is to assess the etiology of delirium comprising the common predisposing factors (tumor, fever, comorbid conditions, infections, altered drugs metabolism, alcohol, and urinary or bowel retention). There is also a need to conduct a careful patient history of onset, duration, and severity of symptoms. During the hospitalization, Delirium Symptom Inventory, Intensive Care Delirium Screening Checklist, and Mini-Mental State Exam are performed at intervals. Diagnostic & Statistical Manual of Mental Disorders, 5th Edition highlights the guidelines for the delirium diagnosis, including the disturbance in attention and changes in cognition not better elucidated by the preexisting evolving or established dementia. The third criterion is the disturbance progresses over a short time, normally hours to days, and fluctuates during the day (American Psychiatric Association, 2013). Finally, there is empirical evidence from the patient’s history, physical examination, and lab findings that disturbance is occasioned by direct physiological effects of underlying medical conditions, intoxicating substances, medication uses, or other causes. Based on the patient’s information and the evidence-based guidelines, the best palliative management of delirium should be achieved.

A multispecialty approach will be used to improve patient’s conditions in palliative care by lessening the symptoms, enhancing the quality of life, and prolonging the chances of survival. In the management, the physician should review, determine the goals of care and ascertain advance directives with both the patient and her family and then document in medical records. The family members will be included to ensure that they have a proper understanding of the illness, management of symptoms, and coping mechanisms. First, the treatment of delirium includes identifying underlying causes, modifying the precipitating factors, and managing symptoms. The numerous underlying causes include infection, metabolic abnormalities, adverse medication effects, organ failure dehydration, and (Breitbart & Alici, 2008). But, among the very ill and dying patients, there could be multiple and irreversible causes. The palliative care approach’s goal is not getting rid of cancer, but the promotion of comfort and relief of suffering to help the patient feel better and live longer with cancer cells in the body. The palliative care, combined with other treatments like chemotherapy, will ease the patient by relieving the symptoms like coughing, pain, and nausea. Moreover, the goal of the delirium palliative care is maintaining cognitive function whenever possible.  An empirical study of hospitalized cancer patients revealed the presence of delusions as one of the most substantial predictors of patient distress (Breitbart et al., 2002). The distress happened for patients with hypoactive or hyperactive delirium.

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In this case, the female patient has been diagnosed with metastatic lung cancer. Appropriate palliative management of delirium is needed. Even though there is no cure for stage IV lung cancer, there are certain treatments that make the symptoms easy to handle. The majority of the time, the surgery will not work for metastatic lung cancer as it has spread. The recommended cancer treatment is a mix of chemotherapy, radiation, and targeted therapies that attack particular parts of cancer cells. Besides, the medications used in the treatment of delirium are opioids, benzodiazepines, anticholinergics, and corticosteroids. Pharmacological management should include the administration of neuroleptics as first-line therapy. If there is a need for sedation, the benzodiazepine can be added, but should not be prescribed as the first-line treatment. The American College Critical Care Medicine recommends that haloperidol is the preferred medication for the treatment of delirium among critically ill adults (Shapiro et al., 1995). The Haloperidol dosage for the mild delirium is 0.5–2.0 mg every 2 to 12 hours, but for more severe symptoms, the dosage is 1 mg 2 to 3 times daily.

The other palliative care interventions available to the patient are the incorporation of non-pharmacological interventions such as supportive methods like the removal of unnecessary stimuli, a safe environment to reduce anxiety, and good sleep hygiene by ensuring a quiet environment with no interventions. The additional interventions are the renewal of fluids and electrolyte balance, environment changes, and relaxation methods like warm drinks, massage, and soothing music. The reorientation to the care environment by staff and family through the placement of familiar objects like pictures could be helpful. The care interventions include careful nutrition and monitoring of the bowel and bladder to avoid dehydration and anxiety triggered by discomfort. The pain must be assessed frequently and treated suitably.

The European Association for Palliative Care, in collaboration with other experts, advocates for the usage of sedation in managing intractable symptoms at the patient’s end of life, comprising agitated delirium, refractory to aggressive measures. The refractory symptoms cannot be sufficiently controlled despite aggressive efforts of identifying an acceptable therapy, which does not compromise one’s consciousness (Dunphy et al., 2019).  When assessing whether the symptoms are refractory, the primary considerations are if further interventions cannot provide adequate relief, excessive or unbearable morbidity, or cannot offer comfort in a well-timed manner. Inherent in the decision-making process is the patient’s informed consent, where possible, and health-care proxy. Since there is a high likelihood of the loss of interactional functioning, it is imperative that both the patient and family members fully understand the consequences of the decision. Finally, the pain and palliative care professional clinician ought to be involved in the decision-making process. The physician will assess whether the patient has a power of attorney and independent mental health advocate to aid in making decisions on estate management, finance, welfare, and health.

References

American Psychiatric Association (2013). Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5®). Washington, D.C: American Psychiatric Publishing.

Breitbart, W., & Alici, Y. (December 24, 2008). Agitation and Delirium at the End of Life: W“e Couldn’t Manage Him”. Journal- American Medical Association, 300, 24, 2898-2910.

Breitbart, W., Gibson, C., & Tremblay, A. (May 01, 2002). The Delirium Experience: Delirium Recall and Delirium-Related Distress in Hospitalized Patients With Cancer, Their Spouses/Caregivers, and Their Nurses. Psychosomatics, 43, 3, 183-194.

Dunphy, L. M. H., In Winland-Brown, J. E., In Porter, B. O., & In Thomas, D. J. (2019). Primary care: The art and science of advanced practice nursing. Philadelphia, PA: F.A. Davis Company.

Shapiro, B. A., Warren, J., Egol, A. B., Greenbaum, D. M., Jacobi, J., Nasraway, S. A., Schein, R. M., Stone, J. R. (January 01, 1995). Practice parameters for intravenous analgesia and sedation for adult patients in the intensive care unit: An executive summary. Critical Care Medicine, 23, 9, 1596.

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