Delirium and sedation

Oxygen is nonbeneficial for most patients who are near death

CONTEXT

Clinicians prescribe and administer oxygen in response to reports of dyspnea, in the face of dropping oxygen saturation, as a "routine" comfort intervention, or to support anxious family members. Oxygen may produce nasal irritation and increase the cost of care.

OBJECTIVES

To determine the benefit of administering oxygen to patients who are near death.

METHODS

A double-blind, repeated-measure observation with the patient as his/her own control was conducted. The Respiratory Distress Observation Scale(©) measured presence and intensity of distress at baseline and at every gas or flow change. Medical air, oxygen, and no flow were randomly alternated every 10 minutes via nasal cannula with patients who were near death, at risk for respiratory distress, with no distress at the baseline of testing. Each patient had two encounters under each condition, yielding six encounters per patient.

RESULTS

Patients were 66% female, 34% white, and 66% African American, and ages 56-97 years. Patients had heart failure (25%), chronic obstructive pulmonary disease (34%), pneumonia (41%), or lung cancer (9%). Most (91%) patients tolerated the protocol with no change in respiratory comfort. Three patients (9%) displayed distress and were restored to baseline oxygen; one patient died during the protocol while displaying no distress. Repeated-measure analysis of variance revealed no differences in the Respiratory Distress Observation Scale under changing gas and flow conditions.

CONCLUSION

The routine application of oxygen to patients who are near death is not supported. The n-of-1 trial of oxygen in clinical practice is appropriate in the face of hypoxemic respiratory distress.

Developing guidelines on the assessment and treatment of delirium in older adults at the end of life

BACKGROUND AND PURPOSE

Delirium at the end of life is common and can have serious consequences on an older person's quality of life and death. In spite of the importance of detecting, diagnosing, and managing delirium at the end of life, comprehensive clinical practice guidelines (CPG) are lacking. Our objective was to develop CPG for the assessment and treatment of delirium that would be applicable to seniors receiving end-of-life care in diverse settings.

METHODS

Using as a starting point the 2006 Canadian Coalition for Seniors' Mental Health CPG on the assessment and treatment of delirium, a team of palliative care researchers and clinicians partnered with members of the original guideline development group to adapt the guidelines for an end-of-life care context. This process was supported by an extensive literature review. The final guidelines were reviewed by external experts.

RESULTS

Comprehensive CPG on the assessment and treatment of delirium in older adults at the end of life were developed and can be downloaded from http://www.ccsmh.ca.

CONCLUSIONS

Further research is needed on the implementation and evaluation of these adapted delirium guidelines for older patients receiving end-of-life care in various palliative care settings.

Patients who are near death are frequently unable to self-report dyspnea

BACKGROUND

Standard measures of dyspnea rely on the patient's self-report. Declining consciousness and/or cognitive function and nearness to death may interfere with dyspnea reporting making the patient vulnerable to undertreatment or overtreatment.

METHODS

An observational design was used with 89 consecutive patients referred for inpatient palliative care consultation. Patients were included if they were at risk for dyspnea because of one or more of the following: lung cancer, chronic obstructive pulmonary disease (COPD), heart failure, or pneumonia. Patients were asked "Are you short of breath?" and asked to quantify any distress by pointing to a visual analogue scale (VAS). Other measures included: consciousness, cognitive state, terminal illness severity, and patient demographics.

RESULTS

More than half of the patients (54%) were unable to provide a yes or no response. Only 20 of 41 (49%) able to respond with yes or no were able to quantify any distress with the VAS. Ability to self-report was positively associated with consciousness (p < 0.01), cognitive state (p < 0.01), and terminal illness severity (p < 0.01). A significant inverse relationship was found between consciousness and terminal illness severity (p < 0.01). Declines in consciousness and cognitive state were strongly correlated with nearness to death (p < 0.01).

CONCLUSIONS

Declining consciousness and/or cognitive state are expected when patients are near death. The ability to give even the simplest self-report (yes or no) about dyspnea is lost in the near-death phase of terminal illness, yet the ability to experience distress may persist and may be overlooked and undertreated or overtreated. Other methods for symptom assessment are needed in this context.

Use of propofol as adjuvant therapy in refractory delirium tremens

Delirium tremens is recognized as a potentially fatal and debilitating complication of alcohol withdrawal. Use of sedatives, particularly benzodiazepines, is the cornerstone of therapy for delirium tremens. But sometimes, very heavy doses of benzodiazepines are required to control delirious symptoms. We are reporting one such case of delirium tremens, which required very heavy doses of benzodiazepines and was ultimately controlled by using infusion of propofol. Thus propofol should always be considered as an option to treat patients with resistant delirium tremens.

[Sedation concepts with volatile anaesthetics in intensive care: practical use and current experiences with the AnaConDa system]

The use of volatile anaesthetics in intensive care medicine has so far been limited by the lack of equipment suitable for daily routine use and the need for an anaesthetic machine. The new Anaesthetic Conserving Device (AnaConDa) enables the routine use of volatile anaesthetics for long-term sedation via intensive care ventilators. The Anaesthetic Conserving Device replaces the common heat and moisture exchanger in the ventilation circuit. The volatile anaesthetic is continuously applied in liquid status via a syringe pump to a form of mini-vaporiser where the anaesthetic agent is vaporised. The expired anaesthetic gas is stored in the carbon filter and approximately 90% of the gas is resupplied into the breathing cycle. The current experiences suggest that volatile anaesthetics present an alternative for long-term sedation in intensive care units, providing optimised pathways, from a medical as well as from an economical point of view. It must, however, be emphasized that the use of volatile anaesthetics for longer periods of time is an off-label use and should only undertaken by medical professionals at their own risk.

Sedation for the care of patients with advanced cancer

Sedation in the context of palliative medicine is the monitored use of medications to induce varying degrees of unconsciousness to bring about a state of decreased or absent awareness (i.e. unconsciousness) in order to relieve the burden of otherwise intractable suffering. Sedation is used in palliative care in several settings: transient controlled sedation, sedation in the management of refractory symptoms at the end of life, emergency sedation, respite sedation, and sedation for refractory psychological or existential suffering. Sedation is controversial in that it diminishes the capacity of the patient to interact, function, and, in some cases, live. There is no distinct ethical problem in the use of sedation to relieve otherwise intolerable suffering in patients who are dying. Since all medical treatments involve risks and benefits, each potential option must be evaluated for its promise with regards to achieving the goals of care. When risks of treatment are involved, to be justified these risks must be proportionate to the gravity of the clinical indication. Some aspects of management, such as the need for hydration in patients undergoing sedation and the use of sedation in the management of psychological and spiritual suffering, remain controversial.

Cognitive assessment and differentiating the 3 Ds (dementia, depression, delirium)

Differentiation between a diminished or altered cognitive functioning asa consequence of aging and one resulting from serious health problems is critical in the elderly. An unrecognized cognitive disorder or the worsening of the impairment may hamper the effectiveness and appropriateness of care and treatment; therefore, standardized assessment procedures and systematic monitoring of cognition and behavior are important aspects of the nursing care. of older adults. In this article, current notions for accurate and comprehensive cognitive assessment in older persons are delineated. Further, an overview of epidemiological screening and diagnostic dilemmas of dementia, depression, and deliriumare provided.