Delirium A. Acute onset and fluctuating course B. Inattention C. - - PDF document

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UCSF Palliative Care Program

Palliative Care Pearls for the Hospitalist

Steven Pantilat, MD Kates-Burnard and Hellman Distinguished Professor in Palliative Care Director, Palliative Care Program University of California, San Francisco Twitter: @stevepantilat

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Disclosure

I published a book: “Life After the Diagnosis: Expert Advice

• n Living Well with Serious Illness for

Patients and Caregivers” No other relevant disclosures

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CDC/NCHS, National Hospital Discharge Survey, 2000–2010

Hospital: 800K/year; 1/3 of all deaths

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Delirium

• A. Acute onset and fluctuating course
• B. Inattention
• C. Disorganized thinking

– Mumbling/rambling speech

• D. Altered level of consciousness

A + B and C or D

Inouye SK et al. Ann Int Med 1990;113:941-8 Oh ES et al. JAMA 2017;318:1161-74

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Delirium at the End of Life

80% Hyperactive 20% Hypoactive 80%

Hosie A et al. Pall Med 2013;27:486-98

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+4 combative +3 very agitated +2 agitated +1 restless 0 alert and calm

• 1 drowsy
• 2 light sedation
• 3 moderate sedation
• 4 deep sedation
• 5 unarousable

Delirium

RASS scale

Very distressing Dying

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Delirium: DDx

• Medications

– Anticholinergics, Steroids, Benzodiazepines, Opioids

• Pain
• Infection
• Metabolic derangements
• Constipation/urinary retention

Vidal M and Bruera E in Hospital-Based Palliative Medicine Pantilat, Anderson, Gonzales, Widera eds. Wiley Blackwell 2015

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Delirium: Prevention

• Orientation

– Family/friends at bedside

• Minimize immobilizing interventions

– Oxygen, IV, suction

• Calming

– Relaxation podcasts, music – Massage – Reduce noise – Minimize awakenings

Hshieh TT et al. JAMA IM 2015;175:512-520

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Risperidone, Haloperidol or Placebo RCT

• 247 palliative care inpatients with delirium
• 75 yo; 72% with cancer; PPS 40
• 0.5mg orally q12hrs, up to 4mg/d

– Half dose for pts >65yo

• Rescue: midazolam 2.5mg sq q2hrs
• Delirium scores every 8 hours
• Outcome: Average of last 2 delirium scores
• n day 3

Agar MR et al. JAMA IM 2017;177:34-42

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Risperidone, Haloperidol or Placebo RCT

• Delirium scores

– Risperidone worse than placebo every day – Haloperidol worse than placebo every day

• Midazolam use

– Fewer placebo patients rescued (17% vs 34%)

• Median survival

– Placebo: 26 days – Risperidone: 17 days – Haloperidol: 16 days

Agar MR et al. JAMA IM 2017;177:34-42

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Haloperidol + Lorazepam vs Haloperidol Alone for Agitated Delirium

• 90 palliative care unit patients with cancer

with hyperactive delirium (RASS ≥ 2 in past 24hrs)

• 62 yo; most with Karnofsky ≤ 30
• Haloperidol 2mg IV q4hrs and 2mg q1hr prn
• RASS score q2hrs; if RASS ≥ 2:

–Lorazepam 3mg IV or placebo

• Outcome: RASS score at 8hrs after

lorazepam

Hui Det al. JAMA 2017;318:1047-56

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Haloperidol + Lorazepam vs Haloperidol Alone for Agitated Delirium

• Median survival 73 hrs; 72% died
• Greater reduction in RASS for haloperidol +

lorazepam

• Absolute RASS at 8hrs

– Haloperidol + lorazepam: -2.5 – Haloperidol : -0.7

• Haloperidol + lorazepam more likely to be

assessed by caregiver as comfortable (84% vs 37%)

Hui Det al. JAMA 2017;318:1047-56

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Treatment of Delirium at the End of Life

• Little evidence of benefit of haloperidol
• Evidence of harm with benzodiazepines
• Assess for treatable causes

– Pain, constipation, urinary retention

• Use nonpharmacologic approaches
• For severe, persistent agitation in the dying

patient, try haloperidol

Neufeld KJ et al. JAGS 2016;64:705-14 Oh ES et al. JAMA 2017;318:1161-74

Give placebo

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Signs of Imminent Death

Hours prior to death mean/median (SD) Death rattle 57/23 (82) Respirations with mandibular movement 8/3 (18) Cyanosis of extremities 5/1 (11) Thready / no radial pulse 3/1 (4) Swelling of hands Cheyne-stokes breathing Pauses in breathing Agonal breathing

Morita T et al. Am J Hosp Pall Care 1998:Jul-Aug:217-22

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Helping Loved Ones

• Support family and friends
• Children
• Spirituality: “Are there any traditions in

your family we should be aware of?”

• Help achieve closure
• Tell stories
• “Forgive me, I forgive you, thank you, I

love you, good-bye”

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Helping Loved Ones

• Offer ideas about how to help
• Wet mouth and lips
• Massage
• Hold hands
• Anticipate issues
• Can she hear me?
• Being present at the time of death
• How will we know?

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Prepare Loved Ones

• Explain signs

– Body shutting down

• Offer prognosis

– Hours to days

• Anticipate surprise

– “May happen suddenly” – “She may wait to be alone to die because it may be too hard to leave you or because she may not want to burden you with it”

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Moment of Death

• How will we know?

– “She will stop breathing”

• Death is not an emergency

– Notify nurse when you are ready – Can stay with your loved one as long as you need

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Helping Loved Ones After the Death

• Next steps

– “We will take care of her” – “You just need to choose a funeral home”

• Request an autopsy
• Make a phone call
• Answer questions
• Alleviate guilt
• Send a card

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Resource for Palliative Care Info

Fast Facts https://www.mypcnow.org/fast-facts Palliative Care Fast Facts app

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There is no good death The goal is to live a good life

UCSF Palliative Care Program UCSF Palliative Care Program UCSF Palliative Care Program

Life After the Diagnosis

• You can live well and long with serious

illness –Palliative care can help you do both

• Talk about what you hope for

–It will encourage and nurture it

• The goal is to live a good life in the

face of serious illness

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