End-of-Life Delirium: Issues Regarding Recognition, Optimal Management, and the Role of Sedation in the Dying Phase

Abstract

Context. In end-of-life care, delirium is often not recognized and poses unique management challenges, especially in the case of refractory delirium in the terminal phase.Objectives. To review: delirium in the terminal phase context, specifically in relation to recognition issues; the decision-making processes and management strategies regarding its reversibility; the potential refractoriness of delirium to symptomatic treatment; and the role of sedation in refractory delirium. Methods.We combined multidisciplinary input from delirium researchers and knowledge users at an international delirium study planning meeting and relevant electronic database literature searches (Ovid Medline, Embase, PsycINFO and CINAHL) to inform this narrative review.Results. The overall management strategy for delirium at the end of life is directed by the patient's prognosis in association with the patient's goals of care. As symptoms of delirium are often refractory in the terminal phase, especially in the case of agitated delirium, the judicious use of palliative sedation is frequently required. However, there remains a lack of high level evidence for the management of delirium in the terminal phase, including the role of antipsychotics and optimal sedation strategies. For the family and health care staff, clear communication, education and emotional support are vital components to assist with decision making and direct the treatment care plan. Conclusion.Further research on the effectiveness of delirium management strategies in the terminal phase for patients and their families is required. Further validation of assessment tools for diagnostic screening and severity measurement are needed in this patient population.

Delirium and its consequences in the specialized palliative care unit: Validation of the Korean version of Memorial Delirium Assessment Scale

“…It is prevalent in patients with cancer and in palliative care settings. In previous studies, the prevalence of delirium in an acute palliative care unit (APCU) varied by up to 42.3%, although it is often unrecognized or under‐diagnosed . The occurrence of delirium leads to a poor medical outcome, including functional deficits, cognitive decline, increased length of hospitalization, and distress to patients and their caregivers .…”

Delirium frequency among advanced cancer patients presenting to an emergency department: A prospective, randomized, observational study

“…Rates of 8% to 17% have been reported in elderly patients seen in general EDs. 3,13,14 We previously observed delirium in more than 40% of hospitalized cancer patients with a high symptom burden who required a palliative care consultation. 8 More than 80% of patients with terminal cancer develop delirium in the last days of life.…”

Les troubles psychiatriques en soins palliatifs et en fin de vie

“…Ce syndrome est une cause de souffrance psychologique importante : chez les patients qui lors des phases de lucidité restent perplexes, angoissés voir traumatisés lorsqu'on les confronte à une réalité qui diffère de celle qu'ils sont en train de vivre ; chez l'entourage familial déjà épuisé par l'accompagnement et traumatisé par cet épisode aigu et la crainte que le proche malade ne termine sa vie dans la folie ; chez les équipes soignantes mises en tension voir en conflits lors de désaccords sur certaines modalités de prise en charge comme la contention physique, notamment en cas de passage hétéro agressif du patient sur un membre du personnel soignant. Sa fréquence en soins palliatifs est importante avec une incidence estimée entre 3 à 45 % [18], une prévalence estimée entre 40 à 62 % lors des admissions en unités de soins palliatifs et de 60 à 88 % dans les dernières semaines ou heures de vie [18][19][20]. Cette entité est un facteur de gravité sur le plan pronostique et reste donc associée à des taux de mortalité élevés pouvant varier entre 10 à 65 % chez des patients déjà fragilisés et menacés par l'évolutivité de leur pathologie somatique [21].…”