Palliative Care and Pain Management at the End of Life ___________________________________________
• Assess psychomotor disturbances by noting whether the patient is restless and agitated or slow and hypoactive. • Ask the patient if he or she is seeing or hearing strange things. • Ask the patient to state the days of the week or months backward, or to give a span of numbers frontward and backward. • Ask the patient open-ended questions, and listen for incoherent speech or tangential thought processes. Clinical assessment and physical examination should also be directed at ruling out underlying causes, such as infection or metabolic abnormalities, and the medication list should be reviewed carefully [310; 384]. Management The treatment of an underlying cause, if identified, is a key step in managing delirium. Whether delirium can be reversed depends on the cause. Delirium caused by psychotropic medica- tions, dehydration, or hypercalcemia is more likely to be revers- ible than delirium caused by hypoxia, metabolic abnormalities, or nonrespiratory infections [380; 387]. Several nonpharmacologic interventions have been success- ful in preventing and managing delirium ( Table 20 ) [310; 380; 382; 384]. If delirium is refractory to nonpharmacologic measures, medications may be prescribed. Level 1 evidence sup- ports the use of haloperidol and chlorpromazine (Thorazine) (typical antipsychotics), and these drugs have the advantage of being available in formulations that allow for multiple routes of administration and of being the most cost-effective [310; 380]. Several systematic reviews have been done to determine the efficacy of antipsychotics for delirium, and although each review has identified only a few well-designed trials, the results have supported the continued use of these drugs ( Table 21 ) [380; 384; 388; 389; 390]. One of these reviews focused on patients with terminal illness; the review identified only one small study (30 subjects) eligible for analysis; haloperidol and chlorpromazine were equally effective, but the risk for cognitive impairment was slightly greater with chlorpromazine [388]. A 2020 update to this review included four studies with 399 participants, most with advanced cancer or advanced AIDS and mild- to moderate-severity delirium [391]. The reviewers found no high-quality evidence to either support or refute the use of drug therapy for delirium symptoms in terminally ill adults. Low-quality evidence indicates that risperidone or haloperidol may slightly worsen delirium symptoms compared with placebo, and moderate- to low-quality evidence indicates that these two agents may slightly increase extrapyramidal adverse events for patients with mild- to moderate-severity delirium [391]. In the other reviews, the efficacy of haloperi- dol was found to be similar to that of olanzapine, risperidone (Risperdal), and quetiapine (Seroquel) (atypical antipsychotics) [389; 390]. In two small nonrandomized studies—one involving hospitalized patients with cancer—aripiprazole (Abilify) was safe and effective for the treatment of delirium, especially the hypoactive subtype [392; 393]. Mild-to-moderate delirium can
be managed with low oral doses of antipsychotics, titrating the dose to optimum relief; higher doses can be used for severe delirium [310; 384]. For older patients and those with multiple comorbidities, treatment should begin with lower doses and titration should be slow [380]. Factors to consider when select- ing a drug include the side-effect profile, the patient’s age and baseline mental status, the time to response, and the subtype of delirium [380]. There is no recommendation regarding the use of other drug classes for delirium in palliative care (e.g., α -2 receptors agonists, cholinesterase inhibitors, melatonergic drugs, psychostimulants) [382]. The goal of treatment is to reach patients’ baseline mental state, not to sedate them, and patients should be reassessed frequently until this goal is met [384]. If agitation is refractory to high doses of haloperidol, the antipsychotic lorazepam may be helpful [310; 384]. Encouraging supportive caregiver pres- ence at the bedside is recommended as a useful adjunct for managing delirium [310]. The management of delirium may also include providing support to family, to help them cope with the condition [310; 384]. The management of terminal delirium will be discussed later in this course. PSYCHOSOCIAL CARE The natural initial reaction to illness that threatens life expec- tancy is emotional, and patients and their families experience a wide range of emotions, including disbelief, anger, fear, and sadness. Over time, these emotions broaden; patients may feel isolated and lonely, anxious about the burden on their fam- ily, or hopeless. Patients expect, or hope, that the healthcare professional in attendance will pay attention, listen carefully, and provide comfort. Beyond personal issues raised for the patient, family members may have guilt about their own well- being, anxiety about the future, and grief about the loss of their loved one. Practical issues such as the cost of care and loss of income from the patient and/or caregiver can add substantially to the feelings of stress. The prevalence of psychological suffering is high during the last year of life, and addressing this aspect of care is integral to the patient’s overall comfort and quality of life. Anxiety and depression are the most common psychological symptoms at the end of life, yet they are among the most underdiagnosed and untreated symptoms [67; 394]. Psychological suffering exacerbates pain and other symptoms, limits the patient’s capacity for pleasurable activities, and causes distress for both the patient and the family [206; 395]. The term “distress” has become standard to describe the psy- chological suffering experienced by patients with life-limiting disease. The NCCN notes that the word “distress” is more acceptable and is associated with less stigma than words such as “psychosocial” or “emotional” [396]. In its guidelines on distress management, the NCCN defines distress as existing “along a continuum, ranging from common normal feelings of vulnerability, sadness, and fears to problems that can become
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