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Finucane AM, Jones L, Leurent B, Sampson EL, Stone P, Tookman A, Candy B. Drug therapy for delirium in terminally ill adults. Cochrane Database Syst Rev 2020; 1:CD004770. [PMID: 31960954 PMCID: PMC6984445 DOI: 10.1002/14651858.cd004770.pub3] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
BACKGROUND Delirium is a syndrome characterised by an acute disturbance of attention and awareness which develops over a short time period and fluctuates in severity over the course of the day. It is commonly experienced during inpatient admission in the terminal phase of illness. It can cause symptoms such as agitation and hallucinations and is distressing for terminally ill people, their families and staff. Delirium may arise from any number of causes and treatment should aim to address these causes. When this is not possible, or treatment is unsuccessful, drug therapy to manage the symptoms may become necessary. This is the second update of the review first published in 2004. OBJECTIVES To evaluate the effectiveness and safety of drug therapies to manage delirium symptoms in terminally ill adults. SEARCH METHODS We searched CENTRAL, MEDLINE, Embase, CINAHL and PsycINFO from inception to July 2019, reference lists of retrieved papers, and online trial registries. SELECTION CRITERIA We included randomised controlled trials of drug therapies in any dose by any route, compared to another drug therapy, a non-pharmacological approach, placebo, standard care or wait-list control, for the management of delirium symptoms in terminally ill adults (18 years or older). DATA COLLECTION AND ANALYSIS We independently screened citations, extracted data and assessed risk of bias. Primary outcomes were delirium symptoms; agitation score; adverse events. Secondary outcomes were: use of rescue medication; cognitive status; survival. We applied the GRADE approach to assess the overall quality of the evidence for each outcome and we include eight 'Summary of findings' tables. MAIN RESULTS We included four studies (three new to this update), with 399 participants. Most participants had advanced cancer or advanced AIDS, and mild- to moderate-severity delirium. Meta-analysis was not possible because no two studies examined the same comparison. Each study was at high risk of bias for at least one criterion. Most evidence was low to very low quality, downgraded due to very serious study limitations, imprecision or because there were so few data. Most studies reported delirium symptoms; two reported agitation scores; three reported adverse events with data on extrapyramidal effects; and none reported serious adverse events. 1. Haloperidol versus placebo There may be little to no difference between placebo and haloperidol in delirium symptoms within 24 hours (mean difference (MD) 0.34, 95% confidence interval (CI) -0.07 to 0.75; 133 participants). Haloperidol may slightly worsen delirium symptoms compared with placebo at 48 hours (MD 0.49, 95% CI 0.10 to 0.88; 123 participants with mild- to moderate-severity delirium). Haloperidol may reduce agitation slightly compared with placebo between 24 and 48 hours (MD -0.14, 95% -0.28 to -0.00; 123 participants with mild- to moderate-severity delirium). Haloperidol probably increases extrapyramidal adverse effects compared with placebo (MD 0.79, 95% CI 0.17 to 1.41; 123 participants with mild- to moderate-severity delirium). 2. Haloperidol versus risperidone There may be little to no difference in delirium symptoms with haloperidol compared with risperidone within 24 hours (MD -0.42, 95% CI -0.90 to 0.06; 126 participants) or 48 hours (MD -0.36, 95% CI -0.92 to 0.20; 106 participants with mild- to moderate-severity delirium). Agitation scores and adverse events were not reported for this comparison. 3. Haloperidol versus olanzapine We are uncertain whether haloperidol reduces delirium symptoms compared with olanzapine within 24 hours (MD 2.36, 95% CI -0.75 to 5.47; 28 participants) or 48 hours (MD 1.90, 95% CI -1.50 to 5.30, 24 participants). Agitation scores and adverse events were not reported for this comparison. 4. Risperidone versus placebo Risperidone may slightly worsen delirium symptoms compared with placebo within 24 hours (MD 0.76, 95% CI 0.30 to 1.22; 129 participants); and at 48 hours (MD 0.85, 95% CI 0.32 to 1.38; 111 participants with mild- to moderate-severity delirium). There may be little to no difference in agitation with risperidone compared with placebo between 24 and 48 hours (MD -0.05, 95% CI -0.19 to 0.09; 111 participants with mild- to moderate-severity delirium). Risperidone may increase extrapyramidal adverse effects compared with placebo (MD 0.73 95% CI 0.09 to 1.37; 111 participants with mild- to moderate-severity delirium). 5. Lorazepam plus haloperidol versus placebo plus haloperidol We are uncertain whether lorazepam plus haloperidol compared with placebo plus haloperidol improves delirium symptoms within 24 hours (MD 2.10, 95% CI -1.00 to 5.20; 50 participants with moderate to severe delirium), reduces agitation within 24 hours (MD 1.90, 95% CI 0.90 to 2.80; 52 participants), or increases adverse events (RR 0.70, 95% CI -0.19 to 2.63; 31 participants with moderate to severe delirium). 6. Haloperidol versus chlorpromazine We are uncertain whether haloperidol reduces delirium symptoms compared with chlorpromazine at 48 hours (MD 0.37, 95% CI -4.58 to 5.32; 24 participants). Agitation scores were not reported. We are uncertain whether haloperidol increases adverse events compared with chlorpromazine (MD 0.46, 95% CI -4.22 to 5.14; 24 participants). 7. Haloperidol versus lorazepam We are uncertain whether haloperidol reduces delirium symptoms compared with lorazepam at 48 hours (MD -4.88, 95% CI -9.70 to 0.06; 17 participants). Agitation scores were not reported. We are uncertain whether haloperidol increases adverse events compared with lorazepam (MD -6.66, 95% CI -14.85 to 1.53; 17 participants). 8. Lorazepam versus chlorpromazine We are uncertain whether lorazepam reduces delirium symptoms compared with chlorpromazine at 48 hours (MD 5.25, 95% CI 0.38 to 10.12; 19 participants), or increases adverse events (MD 7.12, 95% CI 1.08 to 15.32; 18 participants). Agitation scores were not reported. SECONDARY OUTCOMES use of rescue medication, cognitive impairment, survival There were insufficient data to draw conclusions or assess GRADE. AUTHORS' CONCLUSIONS We found no high-quality evidence to support or refute the use of drug therapy for delirium symptoms in terminally ill adults. We found low-quality evidence that risperidone or haloperidol may slightly worsen delirium symptoms of mild to moderate severity for terminally ill people compared with placebo. We found moderate- to low-quality evidence that haloperidol and risperidone may slightly increase extrapyramidal adverse events for people with mild- to moderate-severity delirium. Given the small number of studies and participants on which current evidence is based, further research is essential.
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Affiliation(s)
- Anne M Finucane
- Marie Curie Hospice Edinburgh45 Frogston Road WestEdinburghUKEH10 7DR
- University of EdinburghUsher InstituteEdinburghUK
| | - Louise Jones
- University College LondonMarie Curie Palliative Care Research Department, Division of PsychiatryLondonUK
| | - Baptiste Leurent
- London School of Hygiene and Tropical MedicineDepartment of Medical StatisticsLondonUK
| | - Elizabeth L Sampson
- University College LondonMarie Curie Palliative Care Research Department, Division of PsychiatryLondonUK
| | - Patrick Stone
- University College LondonMarie Curie Palliative Care Research Department, Division of PsychiatryLondonUK
| | | | - Bridget Candy
- University College LondonMarie Curie Palliative Care Research Department, Division of PsychiatryLondonUK
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Affiliation(s)
- Robin L. Fainsinger
- Division of Palliative Medicine, Department of Oncology, University of Alberta, Edmonton, Alberta, Canada
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Prommer EE. Palliative Pharmacotherapy: State-of-the-Art Management of Symptoms in Patients With Cancer. Cancer Control 2015; 22:403-11. [PMID: 26678967 DOI: 10.1177/107327481502200406] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023] Open
Abstract
BACKGROUND Advanced cancer produces multiple symptoms as patients progress through their disease trajectory. Identifying, measuring, and providing therapy for uncontrolled symptoms becomes important because disease-altering therapies may be no longer possible. Symptoms other than pain that cause distress in patients with cancer include delirium, dyspnea, anorexia, nausea, and fatigue. Precise management of these symptoms can lead to the best possible quality of life and lessen distress. This article reviews current management strategies of these symptoms. METHODS The epidemiology, mechanisms, assessment, and therapies of common symptoms in the advanced cancer population are reviewed. RESULTS Identifiable approaches facilitate symptom management in advanced illness. CONCLUSIONS Using a systematic approach to symptoms in advanced illness can improve the quality of life and lessen distress among patients with cancer and their families, friends, and caregivers.
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Affiliation(s)
- Eric E Prommer
- David Geffen School of Medicine, University of California, Los Angeles, CA.
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Candy B, Jackson KC, Jones L, Leurent B, Tookman A, King M. Drug therapy for delirium in terminally ill adult patients. Cochrane Database Syst Rev 2012; 11:CD004770. [PMID: 23152226 DOI: 10.1002/14651858.cd004770.pub2] [Citation(s) in RCA: 37] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
BACKGROUND Delirium is a syndrome characterised by a disturbance of consciousness (often fluctuating), cognition and perception. In terminally ill patients it is one of the most common causes of admission to clinical care. Delirium may arise from any number of causes and treatment should be directed at addressing these causes rather than the symptom cluster. In cases where this is not possible, or treatment does not prove successful, the use of drug therapy to manage the symptoms may become necessary. This is an update of the review published on 'Drug therapy for delirium in terminally ill adult patients' in The Cochrane Library 2004, Issue 2 ( Jackson 2004). OBJECTIVES To evaluate the effectiveness of drug therapies to treat delirium in adult patients in the terminal phase of a disease. SEARCH METHODS We searched the following sources: CENTRAL (The Cochrane Library 2012, Issue 7), MEDLINE (1966 to 2012), EMBASE (1980 to 2012), CINAHL (1982 to 2012) and PSYCINFO (1990 to 2012). SELECTION CRITERIA Prospective trials with or without randomisation or blinding involving the use of drug therapies for the treatment of delirium in adult patients in the terminal phase of a disease. DATA COLLECTION AND ANALYSIS Two authors independently assessed trial quality using standardised methods and extracted trial data. We collected outcomes related to efficacy and adverse effects. MAIN RESULTS One trial met the criteria for inclusion. In the 2012 update search we retrieved 3066 citations but identified no new trials. The included trial evaluated 30 hospitalised AIDS patients receiving one of three agents: chlorpromazine, haloperidol and lorazepam. The trial under-reported key methodological features. It found overall that patients in the chlorpromazine group and those in the haloperidol group had fewer symptoms of delirium at follow-up (to below the diagnostic threshold using the Diagnostic and Statistical Manual of Mental Disorders (DSM-III) and that both were equally effective (at two days mean difference (MD) 0.37; 95% confidence interval (CI) -4.58 to 5.32; between two and six days MD -0.21; 95% CI -5.35 to 4.93). Chlorpromazine and haloperidol were found to be no different in improving cognitive status in the short term (at 48 hours) but at subsequent follow-up cognitive status was reduced in those taking chlorpromazine. Improvements from baseline to day two for patients randomised to lorazepam were not apparent. All patients on lorazepam (n = 6) developed adverse effects, including oversedation and increased confusion, leading to trial drug discontinuation. AUTHORS' CONCLUSIONS There remains insufficient evidence to draw conclusions about the role of drug therapy in the treatment of delirium in terminally ill patients. Thus, practitioners should continue to follow current clinical guidelines. Further research is essential.
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Affiliation(s)
- Bridget Candy
- Marie Curie Palliative Care Research Unit, UCL Mental Health Sciences Unit, University College Medical School, London, UK.
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Gagnon P, Allard P, Gagnon B, Mérette C, Tardif F. Delirium prevention in terminal cancer: assessment of a multicomponent intervention. Psychooncology 2010; 21:187-94. [DOI: 10.1002/pon.1881] [Citation(s) in RCA: 74] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2010] [Revised: 10/14/2010] [Accepted: 10/15/2010] [Indexed: 12/16/2022]
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Geppert CMA, Andrews MR, Druyan ME. Ethical Issues in Artificial Nutrition and Hydration: A Review. JPEN J Parenter Enteral Nutr 2009; 34:79-88. [DOI: 10.1177/0148607109347209] [Citation(s) in RCA: 53] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Affiliation(s)
- Cynthia M. A. Geppert
- From New Mexico Veteran's Affairs Health Care System and University of New Mexico School of Medicine, Albuquerque, New Mexico; El Paso VA Health Care System, El Paso, Texas; and Broad Spectrum Communications, Clarendon Hills, Illinois
| | - Maria R. Andrews
- From New Mexico Veteran's Affairs Health Care System and University of New Mexico School of Medicine, Albuquerque, New Mexico; El Paso VA Health Care System, El Paso, Texas; and Broad Spectrum Communications, Clarendon Hills, Illinois
| | - Mary Ellen Druyan
- From New Mexico Veteran's Affairs Health Care System and University of New Mexico School of Medicine, Albuquerque, New Mexico; El Paso VA Health Care System, El Paso, Texas; and Broad Spectrum Communications, Clarendon Hills, Illinois
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Abstract
Delirium is a troubling complication in hospitalized older patients with cancer. Although preventable and potentially reversible, delirium may be prolonged. Persistent delirium at the time of hospital discharge is common and associated with multiple adverse outcomes. We conducted a secondary data analysis to examine delirium resolution in 43 hospitalized older patients with cancer who had prevalent or incident delirium. We describe trajectories of delirium resolution and evaluate differences in patients with and without delirium resolution. Delirium was assessed using the NEECHAM confusion scale. Forty-one of the 43 patients had delirium during hospitalization before discharge; 2 had delirium only at the time of discharge. Although delirium resolved in 13 patients, a significant majority (70%) had delirium at discharge. Patients with delirium resolution were less functionally impaired before hospitalization and exhibited fewer etiologic risk patterns at admission. Mild delirium was more likely to resolve than severe delirium. All patients with chronic cognitive impairment had persistent delirium. Care for hospitalized older patients with cancer should incorporate delirium prevention and intervention strategies. Caregiver education, communication between providers, and follow-up are critical when delirium persists. Additional research focusing on the management and impact of persistent delirium in hospitalized older patients with cancer is needed.
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Abstract
PURPOSE/OBJECTIVES To provide a comprehensive review of the literature and existing evidence-based findings on delirium in older adults with cancer. DATA SOURCES Published articles, guidelines, and textbooks. DATA SYNTHESIS Although delirium generally is recognized as a common geriatric syndrome, a paucity of empirical evidence exists to guide early recognition and treatment of this sequelae of cancer and its treatment in older adults. Delirium probably is more prevalent than citations note because the phenomenon is under-recognized in clinical practice across varied settings of cancer care. CONCLUSIONS Extensive research is needed to formulate clinical guidelines to manage delirium. A focus on delirium in acute care and at the end of life precludes identification of this symptom in ambulatory care, where most cancer therapies are used. Particular emphasis should address the early recognition of prodromal signs of delirium to reduce symptom severity. IMPLICATIONS FOR NURSING Ongoing assessment opportunities and close proximity to patients' treatment experiences foster oncology nurses' mastery of this common exemplar of altered cognition in older adults with cancer. Increasing awareness of and knowledge delineating characteristics of delirium in older patients with cancer can promote early recognition, optimum treatment, and minimization of untoward consequences associated with the historically ignored example of symptom distress.
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Abstract
PURPOSE/OBJECTIVES To examine key aspects of delirium in a sample of hospitalized older patients with cancer. DESIGN Secondary analysis of data from studies on acute confusion in hospitalized older adults. SETTING Tertiary teaching hospital in the southeastern United States. SAMPLE 76 hospitalized older patients with cancer (mean age = 74.4 years) evenly divided by gender and ethnicity and with multiple cancer diagnoses. METHODS Data were collected during three studies of acute confusion in hospitalized older patients. Delirium was measured with the NEECHAM Confusion Scale on admission, daily during hospitalization, and at discharge. Patient characteristics and clinical risk markers were determined at admission. MAIN RESEARCH VARIABLES Prevalent and incident delirium, etiologic risk patterns, and patient characteristics. FINDINGS Delirium was noted in 43 (57%) patients; 29 (38%) were delirious on admission. Fourteen of 47 (30%) who were not delirious at admission became delirious during hospitalization. Delirium was present in 30 patients (39%) at discharge. Most delirious patients had evidence of multiple (mean = 2.3) etiologic patterns for delirium. CONCLUSIONS Delirium was common in this sample of hospitalized older patients with cancer. Patients with delirium were more severely ill, were more functionally impaired, and exhibited more etiologic patterns than nondelirious patients. IMPLICATIONS FOR NURSING Nurses caring for older patients with cancer should perform systematic and ongoing assessments of cognitive behavioral performance to detect delirium early. The prevention and management of delirium hinge on the identification and treatment of the multiple risk factors and etiologic mechanisms that underlie delirium. The large number of patients discharged while still delirious has significant implications for posthospital care and recovery.
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Affiliation(s)
- Stewart M Bond
- School of Nursing, University of North Carolina at Chapel Hill, USA.
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Michaud L, Burnand B, Stiefel F. Taking care of the terminally ill cancer patient: delirium as a symptom of terminal disease. Ann Oncol 2005; 15 Suppl 4:iv199-203. [PMID: 15477308 DOI: 10.1093/annonc/mdh927] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Affiliation(s)
- L Michaud
- Centre of Clinical Epidemiology, Institute of Social Preventive Medicine, University of Lausanne, Switzerland
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Abstract
BACKGROUND Delirium is a common disorder that often complicates treatment in patients with life-limiting disease. Delirium is described using a variety of terms such as agitation, acute confusional states, encephalopathy, organic mental disorders, and terminal restlessness. Delirium may arise from any number of causes, and treatment should be directed at addressing these causes. In cases where this is not possible, or does not prove successful, the use of drug therapy may become necessary. OBJECTIVES The primary objective of this review was to identify and evaluate studies examining medications used to treat patients suffering from delirium during the terminal phases of disease. SEARCH STRATEGY We searched the following sources: MEDLINE (1966 to July 2003), EMBASE 1980 to July 2003), CINAHL (1982 to July 2003), PSYCH LIT (1974 to July 2003), PSYCHINFO (1990 to July 2003) and the Cochrane Library Volume 2, 2003) for literature pertaining to this topic. SELECTION CRITERIA Prospective trials with or without randomization and/or blinding involving the use of pharmacological agents for the treatment of delirium at the end of life were considered. DATA COLLECTION AND ANALYSIS Two reviewers independently assessed trial quality using standardized methods and extracted data for evaluation. Outcomes related to both efficacy and adverse effects were collected. MAIN RESULTS Thirteen potential studies were identified by the search strategy. Of these, only one study met the criteria for inclusion in this review. This study evaluated 30 hospitalized AIDS patients receiving one of three different agents: chlorpromazine, haloperidol, and lorazepam. Analysis of this trial found chlorpromazine and haloperidol to be equally effective. Chlorpromazine was noted to slightly worsen cognitive function over time but this result was not significant. The lorazepam arm of the study was stopped early as a consequence of excessive sedation. REVIEWERS' CONCLUSIONS The data from one study of 30 patients would perhaps suggest that haloperidol is the most suitable drug therapy for the treatment of patients with delirium near the end of life. Chlorpromazine may be an acceptable alternative if a small risk of slight cognitive impairment is not a concern. However, there is insufficient evidence to draw any conclusions about the role of pharmacotherapy in terminally ill patients with delirium, and further research is essential.
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Affiliation(s)
- K C Jackson
- Pharmacy Practice, Texas Tech University Health Sciences Center, TTUHSC - School of Pharmacy, 36014th Street Mail Stop 8162, Lubbock, Texas 79416, USA
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Kehl KA. Treatment of Terminal Restlessness. J Pain Palliat Care Pharmacother 2004. [DOI: 10.1080/j354v18n01_02] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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McNicol E, Horowicz-Mehler N, Fisk RA, Bennett K, Gialeli-Goudas M, Chew PW, Lau J, Carr D. Management of opioid side effects in cancer-related and chronic noncancer pain: a systematic review. THE JOURNAL OF PAIN 2003; 4:231-56. [PMID: 14622694 DOI: 10.1016/s1526-5900(03)00556-x] [Citation(s) in RCA: 292] [Impact Index Per Article: 13.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
Side effects can limit opioid dosage and reduce quality of life. The purpose of this systematic review was to assess the management of opioid side effects in the context of cancer pain management or, in the event that no evidence was available for cancer pain, for chronic noncancer pain. The side effects studied were constipation, pruritus, nausea and vomiting, myoclonus, sedation, respiratory depression, and delirium. Opioid rotation to manage side effects was also studied. For each side effect, we searched MEDLINE and the Cochrane Controlled Trials Register and identified 657 possible titles for inclusion. Of these, 67 studies met inclusion criteria for analysis. The lack of well-designed, randomized controlled trials and the heterogeneity of populations and study designs made the drawing of firm conclusions difficult and precluded performance of meta-analysis. The type, strength, and consistency of evidence for available interventions to manage opioid side effects vary from strong (eg, on the use of naloxone to reverse respiratory depression or constipation) to weak (eg, changing from the oral to epidural route of morphine administration to manage sedation). Well-designed trials in the specified populations are required to furnish clinicians with secure evidence on managing opioid side effects successfully.
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Affiliation(s)
- Ewan McNicol
- Department of Anesthesia, New England Medical Center and Tufts University School of Medicine, Boston, MA 02111, USA.
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Affiliation(s)
- Patrick J Coyne
- Thomas Palliative Care Unit, Virginia Commonwealth University Health System, Richmond, VA 23298, USA
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Abstract
A critically important aspect of palliative care is the prompt recognition and effective treatment of psychiatric complications. Psychiatric syndromes such as depression, anxiety, confusion, suicidal ideation, and wish for hastened death or assisted-suicide occur in a significant percentage of patients with advanced illness. This article reviews their frequency, diagnosis, associated factors, and management to help expand the focus of palliative care beyond pain and physical symptom control.
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Affiliation(s)
- A Tremblay
- Psychiatry Services, Department of Psychiatry and Behavioral Sciences, Memorial Sloan Kettering Cancer Center, New York, New York 10021, USA
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Abstract
Knowledge about acute confusion (AC) has grown rapidly during the past decade, but very few studies have focused specifically on AC episodes associated with the end of life. Although experienced oncology clinicians accept that AC is common near the end of life, little is known about the frequency, nature, course, and timing of AC during this critical stage of life in patients with terminal cancer. Data suggest patients with advanced cancer have reversible causes of delirium, where appropriate treatment can result in improved outcomes. The data for this article are drawn from a larger study investigating the incidence, prevalence, behaviors, and outcomes of AC in acutely ill medical patients. The diagnosis of AC was ascertained using the NEECHAM Confusion Scale. Of the 117 participants included in the larger study, 16 developed delirium (cumulative incidence estimate, 14%) and 10 died within 1 year of the index hospitalization. These 10 cases were categorized in two groups: those with a cancer-related diagnosis (n = 6) and those without cancer (n = 4). To further describe the nature of AC near the end of life, two case studies are presented. Because all previous studies were conducted using samples consisting of patients with cancer, it is unknown whether the findings reported in previous studies hold for other terminal illnesses, such as chronic obstructive pulmonary disease or heart failure. The data presented in this article suggest there are differences in baseline vulnerability (e.g., cognitive status) and the timing of AC in relation to death. These differences need to be explored in a larger sample of individuals both with and without a diagnosis of cancer. The severity and course of AC in the terminally ill population needs to be described to gain a better understanding of end-of-life AC phenomenology (e.g., signs, patterns, subtypes). Armed with this information, health care providers will then be able to develop and test AC-specific treatments of patients, as well as counsel and support family members of patients experiencing AC.
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Affiliation(s)
- B Wakefield
- Iowa City Veterans Affairs Medical Center, College of Nursing, University of Iowa, USA
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Gagnon P, Allard P, Mâsse B, DeSerres M. Delirium in terminal cancer: a prospective study using daily screening, early diagnosis, and continuous monitoring. J Pain Symptom Manage 2000; 19:412-26. [PMID: 10908822 DOI: 10.1016/s0885-3924(00)00143-3] [Citation(s) in RCA: 101] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
A pilot prospective cohort study was conducted to determine delirium frequency and outcome in cancer patients consecutively hospitalized for terminal care (median stay: 12 days). Screening for delirium symptoms was performed daily, using the Confusion Rating Scale. Patients positive on screening had a diagnostic assessment within 24 hours using the Confusion Assessment Method. Monitoring of symptoms was continued until death. Eighteen (20%) of the 89 study patients were positive on screening at admission. Among the 71 patients free of delirium at admission, the incidence of confirmed delirium was 32. 8% (95% CI, 21.3-44.3%). Patients positive on screening received a higher mean equivalent parenteral daily dose of morphine than other patients (72 mg vs. 41 mg, p = 0.08). Significant symptom improvement occurred in 16 (50%) of the 32 delirious cases. Delirium is a serious and frequent complication in terminal cancer whose outcome may not be as poor as previously considered.
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Affiliation(s)
- P Gagnon
- The Maison Michel Sarrazin, Laval University, Québec City, Province of Québec, Canada
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Chochinov HM. Psychiatry and terminal illness. CANADIAN JOURNAL OF PSYCHIATRY. REVUE CANADIENNE DE PSYCHIATRIE 2000; 45:143-50. [PMID: 10742873 DOI: 10.1177/070674370004500204] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
OBJECTIVE To provide an overview of the palliative care literature salient to the psychiatric aspect of end-of-life care. METHOD A literature review was conducted, targeting primarily empirical studies that addressed the following topics: 1) psychological issues pertaining to life-threatening conditions; 2) family issues in the context of palliative care; 3) psychological issues and challenges faced by end-of-life health care providers; and 4) psychiatric disorders, including depression, anxiety, and organic mental disorders, in people with terminal illness. RESULTS There is a small but emerging literature that can guide psychiatrists in their role of providing care to dying patients. CONCLUSIONS While psychiatry has made tremendous inroads toward providing care to patients throughout the life cycle, its presence is only just beginning to be felt in end-of-life care. Within the domain of palliative care, psychiatry has an expanded and important role to play.
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Affiliation(s)
- H M Chochinov
- Division of Palliative Care, University of Manitoba, Winnipeg.
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Abstract
While the majority of end-stage renal disease (ESRD) patients on dialysis lead satisfying lives, an increasing number are choosing to withdraw from dialysis before death. A partnership between nephrology and palliative care/hospice healthcare teams would seem likely in the care of ESRD patients, yet this is often not the case. In anticipation of increasing participation by palliative care/hospice teams in the care of such patients, this article reviews the decision-making process of withdrawal and the medical care of the patient who withdraws. While withdrawal can be an acceptable choice from a medical, legal, psychiatric, and ethical point of view, it can nonetheless be complex. Profound decisions are often characterized by the need for time to process, and by ambivalence among patient, family and healthcare providers. In addition to caring for the patient and family, the palliative care/hospice team will want to consider the needs of the referring nephrology team as well. A "uremic death" is characterized as painless; however, other symptoms related to the accumulation of toxins and fluid can be anticipated and managed. Pharmacological intervention of uremic symptoms, as well as the pain attendant to other, nonrenal comorbid disease is accomplished with awareness of the impact of renal failure on the excretion of various drugs and their metabolites.
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Affiliation(s)
- K J Neely
- Northwestern University Medical School, Division of General Internal Medicine, Chicago, Illinois 60611, USA.
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Voltz R, Akabayashi A, Reese C, Ohi G, Sass HM. Attitudes of Healthcare Professionals Toward Clinical Decisions in Palliative Care: A Cross-Cultural Comparison. THE JOURNAL OF CLINICAL ETHICS 1999. [DOI: 10.1086/jce199910406] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
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Abstract
The appropriate limit or scope of investigation and treatment of the palliative patient is an evolving and still controversial area. Major differences of opinion persist. This case report highlights such differences. The ethics of decision-making in palliative care are discussed and a series of practical steps that may help in these dilemmas is briefly highlighted.
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Affiliation(s)
- A W Taube
- Regional Palliative Care Program, Grey Nuns Community Health Centre, Edmonton, Alberta, Canada
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Abstract
In recent years major developments have taken place in palliative cancer care. Cancer specialists should be familiar with a number of these developments since they can improve symptom control in advanced cancer patients. Some of these developments are discussed in this article, with particular emphasis on the multidimensional assessment of symptom complexes and neurotoxicity of opioids.
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Affiliation(s)
- E Bruera
- Grey Nuns Community Hospital & Health Centre, Edmonton Regional Palliative Care Program, University of Alberta, Canada
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26
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Fainsinger RL, Landman W, Hoskings M, Bruera E. Sedation for uncontrolled symptoms in a South African hospice. J Pain Symptom Manage 1998; 16:145-52. [PMID: 9769616 DOI: 10.1016/s0885-3924(98)00066-9] [Citation(s) in RCA: 68] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
The need to sedate terminally ill patients for uncontrolled symptoms has been previously documented in a few reports. A retrospective consecutive chart review was undertaken at a hospice in Cape Town, South Africa, to develop an understanding of the local experience and assess the potential for improved patient management. Twenty-three of seventy-six (30%) patients received sedating therapies: twenty patients for delirium, two patients for delirium and dyspnea, and one patient for dyspnea alone. Fourteen patients were sedated with a continuous subcutaneous infusion of midazolam, seven patients with intermittent doses of benzodiazepines, and two patients with chlorpromazine and lorazepam. The mean midazolam dose was 29 mg per day (median 30 mg; range 15-60 mg per day). Patients were sedated on average 2.5 days before death (median 1 day; range 4 hours-12 days). The mean equivalent daily dose of parenteral morphine in the last week of life showed a significantly higher mean for the sedated group, as compared to the nonsedated group. There was minimal investigation of reversible causes for delirium, none of the patients underwent an opioid rotation, and the opioid dose was seldom decreased. None of the patients received parenteral hydration. The prevalence for the use of sedating treatment is consistent with the range of other literature reports. Nevertheless, the wide disparity in the reported prevalence of these problems, and the ethical concerns raised by the relative frequency of this sedative approach, cannot be ignored.
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Affiliation(s)
- R L Fainsinger
- Division of Palliative Medicine, University of Alberta, Edmonton, Canada
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27
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Affiliation(s)
- J L Shuster
- Department of Psychiatry, School of Medicine, University of Alabama, Birmingham, Alabama 35294-0018, USA
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28
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Affiliation(s)
- Jose Pereira
- Palliative Care Program, Grey Nuns Community Health Centre, Cross Cancer Institute, University of Alberta, Edmonton, Alberta, Canada
| | - John Hanson
- Palliative Care Program, Grey Nuns Community Health Centre, Cross Cancer Institute, University of Alberta, Edmonton, Alberta, Canada
| | - Eduardo Bruera
- Palliative Care Program, Grey Nuns Community Health Centre, Cross Cancer Institute, University of Alberta, Edmonton, Alberta, Canada
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29
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Affiliation(s)
- Jose Pereira
- Palliative Care Program, Grey Nuns Community Health Centre, Cross Cancer Institute, University of Alberta, Edmonton, Alberta, Canada
| | - John Hanson
- Palliative Care Program, Grey Nuns Community Health Centre, Cross Cancer Institute, University of Alberta, Edmonton, Alberta, Canada
| | - Eduardo Bruera
- Palliative Care Program, Grey Nuns Community Health Centre, Cross Cancer Institute, University of Alberta, Edmonton, Alberta, Canada
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30
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Musgrave CF, Bartal N, Opstad J. Intravenous hydration for terminal patients: what are the attitudes of Israeli terminal patients, their families, and their health professionals? J Pain Symptom Manage 1996; 12:47-51. [PMID: 8718916 DOI: 10.1016/0885-3924(96)00048-6] [Citation(s) in RCA: 34] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
Dehydration in terminally ill patients is a common condition and its treatment in an active oncology unit often involves intravenous (IV) hydration programs. The decision to use IV hydration is only partly determined by an objective assessment of the clinical data. The other component is the attitudes of those involved in the decision-making process. This pilot study surveyed the attitudes of patients, family members/friends, nurses and doctors toward IV hydration in this patient population. Although the majority of the conscious patients (95%), family members/friends (81%), and nurses (64%) were not involved in the decision-making process, the expressed attitudes were generally positive. The three most commonly stated reasons for IV therapy were "medication," "giving fluids" and "giving morphine." Interestingly, among the reasons expressed, the amelioration of thirst was never explicitly cited.
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Affiliation(s)
- C F Musgrave
- Hebrew University-Hadassah School of Nursing, Jerusalem, Israel
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