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Faeder M, Hale E, Hedayati D, Israel A, Moschenross D, Peterson M, Peterson R, Piechowicz M, Punzi J, Gopalan P. Preventing and treating delirium in clinical settings for older adults. Ther Adv Psychopharmacol 2023; 13:20451253231198462. [PMID: 37701890 PMCID: PMC10493062 DOI: 10.1177/20451253231198462] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/24/2023] [Accepted: 08/11/2023] [Indexed: 09/14/2023] Open
Abstract
Delirium is a serious consequence of many acute or worsening chronic medical conditions, a side effect of medications, and a precipitant of worsening functional and cognitive status in older adults. It is a syndrome characterized by fluctuations in cognition and impaired attention that develops over a short period of time in response to an underlying medical condition, a substance (prescribed, over the counter, or recreational), or substance withdrawal and can be multi-factorial. We present a narrative review of the literature on nonpharmacologic and pharmacologic approaches to prevention and treatment of delirium with a focus on older adults as a vulnerable population. Older adult patients are most at risk due to decreasing physiologic reserves, with delirium rates of up to 80% in critical care settings. Presentation of delirium can be hyperactive, hypoactive, or mixed, making identification and study challenging as patients with hypoactive delirium are less likely to come to attention in an inpatient or long-term care setting. Studies of delirium focus on prevention and treatment with nonpharmacological or medication interventions, with the preponderance of evidence favoring multi-component nonpharmacological approaches to prevention as the most effective. Though use of antipsychotic medication in delirium is common, existing evidence does not support routine use, showing no clear benefit in clinically significant outcome measures and with evidence of harm in some studies. We therefore suggest that antipsychotics be used to treat agitation, psychosis, and distress associated with delirium at the lowest effective doses and shortest possible duration and not be considered a treatment of delirium itself. Future studies may clarify the use of other agents, such as melatonin and melatonin receptor agonists, alpha-2 receptor agonists, and anti-epileptics.
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Affiliation(s)
- Morgan Faeder
- University of Pittsburgh School of Medicine, 3811 O’Hara Street, Pittsburgh, PA 15261, USA
| | - Elizabeth Hale
- University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Daniel Hedayati
- University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Alex Israel
- University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | | | - Melanie Peterson
- University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Ryan Peterson
- University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Mariel Piechowicz
- University of Pittsburgh Medical Center Health System, Pittsburgh, PA, USA
| | - Jonathan Punzi
- University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Priya Gopalan
- University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
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Matsuda Y, Tanimukai H, Inoue S, Hirayama T, Kanno Y, Kitaura Y, Inada S, Sugano K, Yoshimura M, Harashima S, Wada S, Hasegawa T, Okamoto Y, Dotani C, Takeuchi M, Kako J, Sadahiro R, Kishi Y, Uchida M, Ogawa A, Inagaki M, Okuyama T. A revision of JPOS/JASCC clinical guidelines for delirium in adult cancer patients: a summary of recommendation statements. Jpn J Clin Oncol 2023; 53:808-822. [PMID: 37190819 DOI: 10.1093/jjco/hyad042] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2023] [Accepted: 04/26/2023] [Indexed: 05/17/2023] Open
Abstract
OBJECTIVE The Japanese Psycho-Oncology Society and the Japanese Association of Supportive Care in Cancer have recently revised the clinical practice guidelines for delirium in adult cancer patients. This article reports the process of developing the revised guidelines and summarizes the recommendations made. METHODS The guidelines were developed in accordance with the Medical Information Network Distribution Service creation procedures. The guideline development group, consisting of multi-disciplinary members, created three new clinical questions: non-pharmacological intervention and antipsychotics for the prevention of delirium and trazodone for the management of delirium. In addition, systematic reviews of nine existing clinical questions have been updated. Two independent reviewers reviewed the proposed articles. The certainty of evidence and the strength of the recommendations were graded using the grading system developed by the Medical Information Network Distribution Service, following the concept of The Grading of Recommendations Assessment, Development, and Evaluation system. The modified Delphi method was used to validate the recommended statements. RESULTS This article provides a compendium of the recommendations along with their rationales, as well as a short summary. CONCLUSIONS These revised guidelines will be useful for the prevention, assessment and management of delirium in adult cancer patients in Japan.
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Affiliation(s)
- Yoshinobu Matsuda
- Department of Psychosomatic Internal Medicine, Kinki-Chuo Chest Medical Center, Sakai, Japan
| | - Hitoshi Tanimukai
- Faculty of Human Health Sciences, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Shinichiro Inoue
- Department of Neuropsychiatry, Okayama University Hospital, Dentistry, and Pharmaceutical Science, Okayama, Japan
| | - Takatoshi Hirayama
- Department of Psycho-Oncology, National Cancer Center Hospital, Tokyo, Japan
| | - Yusuke Kanno
- Department of Home Health and Palliative Care Nursing, Graduate School of Health Care Sciences, Tokyo Medical and Dental University, Tokyo, Japan
| | - Yuichi Kitaura
- Department of Psychiatry, Panasonic Health Insurance Organization Matsushita Memorial Hospital, Moriguchi, Japan
| | - Shuji Inada
- Department of Psychosomatic Medicine, Faculty of Medicine, Kindai University, Osaka-Sayama, Japan
| | - Koji Sugano
- Division of Respiratory Medicine, Juntendo Tokyo Koto Geriatric Medical Center, Tokyo, Japan
| | - Masafumi Yoshimura
- Department of Occupational Therapy, Faculty of Rehabilitation, Kansai Medical University, Hirakata, Japan
| | - Saki Harashima
- Department of Stress Sciences and Psychosomatic Medicine, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Saho Wada
- Department of Neuropsychiatry, Nippon Medical School Tamanagayama Hospital, Tokyo, Japan
| | - Takaaki Hasegawa
- Center for Psycho-oncology and Palliative Care, Nagoya City University Hospital, Nagoya, Japan
| | - Yoshiaki Okamoto
- Department of pharmacy, Ashiya Municipal Hospital, Ashiya, Japan
| | - Chikako Dotani
- Department of Pediatrics, The University of Tokyo Hospital, Tokyo, Japan
| | - Mari Takeuchi
- Department of Neuropsychiatry, Keio University School of Medicine, Tokyo, Japan
| | - Jun Kako
- College of Nursing Art and Science, University of Hyogo, Akashi, Japan
| | - Ryoichi Sadahiro
- Department of Psycho-Oncology, National Cancer Center Hospital, Tokyo, Japan
| | - Yasuhiro Kishi
- Department of Psychiatry, Nippon Medical School Musashikosugi Hospital, Kawasaki, Japan
| | - Megumi Uchida
- Department of Psychiatry and Cognitive-Behavioral Medicine, Nagoya City University Graduate School of Medical Sciences, Nagoya, Japan
| | - Asao Ogawa
- Division of Psycho-Oncology, Exploratory Oncology Research and Clinical Trial Center, National Cancer Center, Kashiwa, Japan
| | - Masatoshi Inagaki
- Department of Psychiatry, Faculty of Medicine, Shimane University, Izumo, Japan
| | - Toru Okuyama
- Department of Psychiatry/Palliative Care Center, Nagoya City University West Medical Center, Nagoya, Japan
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Featherstone I, Siddiqi N, Jones L, Coppo E, Sheldon T, Hosie A, Wolkowski A, Bush SH, Taylor J, Teodorczuk A, Johnson MJ. 'It's tough. It is hard': A qualitative interview study of staff and volunteers caring for hospice in-patients with delirium. Palliat Med 2023:2692163231170655. [PMID: 37129262 DOI: 10.1177/02692163231170655] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/03/2023]
Abstract
BACKGROUND Delirium is a distressing condition often experienced by hospice in-patients. Increased understanding of current multidisciplinary care of delirium is needed to develop interventions in this setting. AIM(S) To explore hospice staff and volunteers' practice, its influences and what may need to change to improve hospice delirium care. DESIGN Qualitative interview study using behaviour change theory from a critical realist stance. SETTING/PARTICIPANTS Thirty-seven staff, including different professional groups and roles, and volunteers were purposively sampled from two in-patient hospices. RESULTS We found that participants' practice focus was on managing hyperactive symptoms of delirium, through medication use and non-pharmacological strategies. Delirium prevention, early recognition and hypoactive delirium received less attention. Our theoretically-informed analysis identified this focus was influenced by staff and volunteers' emotional responses to the distress associated with hyperactive symptoms of delirium as well as understanding of delirium prevention, recognition and care, which varied between staff groups. Non-pharmacological delirium management was supported by adequate staffing levels, supportive team working and a culture of person-centred and family-centred care, although behaviours that disrupted the calm hospice environment challenged this. CONCLUSIONS Our findings can inform hospice-tailored behaviour change interventions that develop a shared team understanding and engage staff's emotional responses to improve delirium care. Reflective learning opportunities are needed that increase understanding of the potential to reduce patient distress through prevention and early recognition of delirium, as well as person-centred management. Organisational support for adequate, flexible staffing levels and supportive team working is required to support person-centred delirium care.
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Affiliation(s)
| | - Najma Siddiqi
- Department of Health Sciences, University of York, York, UK
- Hull York Medical School, University of Hull, Hull, UK
| | - Lesley Jones
- Hull York Medical School, University of Hull, Hull, UK
| | - Eleonora Coppo
- Cardinal Massaia Hospital of Asti, Asti, Piemonte, Italy
| | - Trevor Sheldon
- Wolfson Institute of Population Health, Barts and The London School of Medicine and Dentistry, Queen Mary University, London, UK
| | - Annmarie Hosie
- School of Nursing, The University of Notre Dame Australia, Sydney, NSW, Australia
- The Cunningham Centre for Palliative Care, St Vincent's Health Network, Sydney, NSW, Australia
- IMPAACT, Faculty of Health, University of Technology Sydney, Sydney, NSW, Australia
| | | | - Shirley H Bush
- Department of Medicine, Division of Palliative Care, University of Ottawa, Ottawa, ON, Canada
- Bruyere Research Institute, Ottawa, ON, Canada
- Ottawa Hospital Research Institute, Ottawa, ON, Canada
| | - Johanna Taylor
- Department of Health Sciences, University of York, York, UK
| | - Andrew Teodorczuk
- Faculty of Medicine, The University of Queensland, Brisbane, QLD, Australia
- The Prince Charles Hospital, Metro North Mental Health, Brisbane, QLD, Australia
- School of Medicine and Dentistry, Griffith University, Southport, QLD, Australia
| | - Miriam J Johnson
- Wolfson Palliative Care Research Centre, Hull York Medical School, University of Hull, Hull, UK
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Ijaopo EO, Zaw KM, Ijaopo RO, Khawand-Azoulai M. A Review of Clinical Signs and Symptoms of Imminent End-of-Life in Individuals With Advanced Illness. Gerontol Geriatr Med 2023; 9:23337214231183243. [PMID: 37426771 PMCID: PMC10327414 DOI: 10.1177/23337214231183243] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2023] [Revised: 05/23/2023] [Accepted: 05/31/2023] [Indexed: 07/11/2023] Open
Abstract
Background: World population is not only aging but suffering from serious chronic illnesses, requiring an increasing need for end-of-life care. However, studies show that many healthcare providers involved in the care of dying patients sometimes express challenges in knowing when to stop non-beneficial investigations and futile treatments that tend to prolong undue suffering for the dying person. Objective: To evaluate the clinical signs and symptoms that show end-of-life is imminent in individuals with advanced illness. Design: Narrative review. Methods: Computerized databases, including PubMed, Embase, Medline,CINAHL, PsycInfo, and Google Scholar were searched from 1992 to 2022 for relevant original papers written in or translated into English language that investigated clinical signs and symptoms of imminent death in individuals with advanced illness. Results: 185 articles identified were carefully reviewed and only those that met the inclusion criteria were included for review. Conclusion: While it is often difficult to predict the timing of death, the ability of healthcare providers to recognize the clinical signs and symptoms of imminent death in terminally-ill individuals may lead to earlier anticipation of care needs and better planning to provide care that is tailored to individual's needs, and ultimately results in better end-of-life care, as well as a better bereavement adjustment experience for the families.
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Affiliation(s)
| | - Khin Maung Zaw
- University of Miami Miller School of Medicine, FL, USA
- Miami VA Medical Center, FL, USA
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Oya K, Morita T, Tagami K, Matsuda Y, Naito AS, Kashiwagi H, Otani H. Physicians' Beliefs and Attitudes Toward Hypoactive Delirium in The Last Days of Life. J Pain Symptom Manage 2022; 64:110-118. [PMID: 35490994 DOI: 10.1016/j.jpainsymman.2022.04.176] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/23/2021] [Revised: 04/17/2022] [Accepted: 04/18/2022] [Indexed: 12/31/2022]
Abstract
CONTEXT The perspective toward hypoactive delirium in the last days of life could be different among physicians. OBJECTIVES To clarify the attitudes, beliefs, and opinions of palliative care physicians and liaison psychiatrists toward hypoactive delirium in the last days of life and to explore the association among these factors. METHODS A nationwide cross-sectional questionnaire survey was conducted among 1667 physicians who were either certified palliative care specialists or liaison psychiatrists. Physicians' agreement with the appropriateness of pharmacological management (e.g., antipsychotics) (one item), their beliefs (11 items), and their opinions (four items) were measured. RESULTS 787 (47%) physicians responded. 481 (62%) agreed to use of medications for hypoactive delirium in the last days of life, whereas 296 (38.1%) disagreed. More than 95% agreed with "hypoactive delirium at the end of life can be considered as a part of natural dying process." Multivariate analysis identified two belief subscales of "hypoactive delirium at the end of life is a natural dying process" and "antipsychotics are futile and harmful in managing hypoactive delirium" had a significant negative correlation with the use of medications. On the other hand, one belief subscale of "hypoactive delirium can be distressing even if patients' consciousness is impaired" had significant positive correlations with the use of medications. CONCLUSION Pharmacological management of hypoactive delirium in the last days of life differs depending on physicians' beliefs. Future research is needed to clarify the efficacy and safety of pharmacological management of hypoactive delirium.
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Affiliation(s)
- Kiyofumi Oya
- Peace Home Care Clinic, Otsu, (K.O,) Shiga, Japan; Clinical Research Support Office, (K.O., T.M) Iizuka Hospital, Iizuka-shi, Fukuoka, Japan.
| | - Tatsuya Morita
- Department of Palliative and Supportive Care, Palliative Care Team, Seirei Mikatahara General Hospital, 3453 Mikatahara-cho, Kita-ku, Hamamatsu, (T.M.) Shizuoka Japan
| | - Keita Tagami
- Department of Palliative Medicine, Tohoku University Graduate School of Medicine, Sendai, (K.T.) Miyagi, Japan
| | - Yoshinobu Matsuda
- Department of Psychosomatic Internal Medicine, National Hospital Organization Kinki-Chuo Chest Medical Center, Sakai, (Y.M.) Osaka, Japan
| | - Akemi Shirado Naito
- Department of Palliative Care, Miyazaki Medical Association Hospital, Miyazaki-shi, (A.S.N.) Miyazaki, Japan
| | - Hideyuki Kashiwagi
- Department of Transitional and Palliative Care, Iizuka Hospital, Iizuka-shi, (H.K.) Fukuoka, Japan
| | - Hiroyuki Otani
- Department of Palliative Care Team, and Palliative and Supportive Care, National Hospital Organization Kyushu Cancer Center, Mitami-ku, (H.O.) Fukuoka Japan
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Kim SY, Jhon M, Kang HJ, Lee JY, Kim SW, Kim JM, Shin IS. Depressed mood, associated factors, and understanding of delirium among caregivers of patients with delirium. Int J Psychiatry Med 2022; 57:153-164. [PMID: 33653170 DOI: 10.1177/0091217421989146] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
OBJECTIVE Delirium is stressful for both the patient and caregiver. However, caregivers have attracted minimal attention. We here identify depressed moods and associated factors among caregivers and caregiver knowledge of the delirium and non-pharmacological management. METHODS This was a cross-sectional study. Caregiver and patient demographic characteristics, and patient clinical data, were collected. Caregiver depressed mood was analysed using the Hospital Anxiety and Depression Scale-depression subscale (HADS-D). We explored caregiver understanding of delirium and knowledge of non-pharmacological management. We used a multivariate linear regression model to identify factors associated with caregiver depressed mood. RESULTS For 224 caregivers, the median (interquartile range) HADS-D score was 8.0 (4.0-11.8). More than half (54.9%) had scores ≥8. Answers to multiple choice questions revealed that delirium was frequently misinterpreted as "anxiety" (25.9%) or "dementia" (25.4%). Of all caregivers, 74% had received no information on non-pharmacological delirium management. Younger age of patient, a longer time from delirium detection to consultation, a patient past history of depression, a spousal relation with the patient, and misinterpretation of delirium as dementia were associated with the depressed mood of caregivers. CONCLUSIONS The mental health of caregivers of patients with delirium requires more attention; they should be recommended to be informed and educated about delirium. Also, the clinicians need to find an easier term for the delirium to help caregivers understand.
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Affiliation(s)
- Seon-Young Kim
- Department of Psychiatry, Chonnam National University Medical School, Gwangju, Republic of Korea.,Mental Health Clinic, Chonnam National University Hwasun Hospital, Hwasun, Republic of Korea
| | - Min Jhon
- Mental Health Clinic, Chonnam National University Hwasun Hospital, Hwasun, Republic of Korea
| | - Hee-Ju Kang
- Department of Psychiatry, Chonnam National University Medical School, Gwangju, Republic of Korea
| | - Ju-Yeon Lee
- Department of Psychiatry, Chonnam National University Medical School, Gwangju, Republic of Korea
| | | | - Jae-Min Kim
- Department of Psychiatry, Chonnam National University Medical School, Gwangju, Republic of Korea
| | - Il-Seon Shin
- Department of Psychiatry, Chonnam National University Medical School, Gwangju, Republic of Korea
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Association of Nutritional Status with New-Onset Delirium in Elderly, Acute Care, Orthopaedic Trauma Patients: A Single-Center Observational Study. J Orthop Trauma 2022; 36:67-72. [PMID: 35061654 DOI: 10.1097/bot.0000000000002213] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/11/2021] [Indexed: 02/02/2023]
Abstract
OBJECTIVE To determine whether nutritional status at hospital admission is independently associated with new-onset delirium (NOD) in elderly, orthopaedic trauma patients. DESIGN Single-center, retrospective, cross-sectional study. SETTING Data from patients at a large teaching hospital in Boston, MA, were analyzed. PATIENTS All patients were ≥65 years and hospitalized for acute surgical management of their major fractures after trauma. INTERVENTION None. MAIN OUTCOME MEASUREMENT Nutritional status was assessed at admission using the Mini Nutritional Assessment-Short Form (MNA-SF). Delirium was assessed using the Confusion Assessment Method within 24 hours of admission and daily throughout hospitalization. RESULTS The incidence of delirium was 20% (94/471). Each unit decrement in MNA-SF was associated with a 14% higher risk of NOD (adjusted OR 1.14; 95% CI 1.05-1.28). Moreover, malnourished patients (MNA-SF score 0-7) were twice as likely to develop NOD (adjusted OR 2.07; 95% CI 1.01-4.35) compared with patients who were not malnourished (MNA-SF score 8-14). CONCLUSIONS In hospitalized, elderly, orthopaedic trauma patients, poor nutritional status may be a modifiable risk factor for NOD. Future studies are needed to determine whether aggressive nutritional interventions can reduce the incidence of NOD and improve outcomes in this cohort of patients. LEVEL OF EVIDENCE Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.
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White L, Jackson T. Delirium and COVID‐19: a narrative review of emerging evidence. Anaesthesia 2022; 77 Suppl 1:49-58. [DOI: 10.1111/anae.15627] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/08/2021] [Indexed: 12/27/2022]
Affiliation(s)
- L. White
- Institute of Inflammation and Ageing University of Birmingham Birmingham UK
| | - T. Jackson
- Institute of Inflammation and Ageing University of Birmingham Birmingham UK
- University Hospitals Birmingham NHS Foundation Trust Birmingham UK
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Tham K, Shiu A, William L, Walpole G, Rashed S. Refractory hyperactive delirium in the dying: pharmacological management. BMJ Support Palliat Care 2021; 12:471-474. [PMID: 34819327 DOI: 10.1136/bmjspcare-2021-003139] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2021] [Accepted: 10/21/2021] [Indexed: 11/04/2022]
Abstract
BACKGROUND Delirium is a prevalent clinical presentation in advanced illness. The hyperactive phase can cause severe symptoms at the end of life. There is no published study of the pharmacological management of this symptom in Australian palliative medicine practice. OBJECTIVES To describe the pharmacological management of hyperactive delirium at the end of life in an Australian inpatient palliative care setting. METHODS Retrospective audit of deaths from October 2019 where a medication of interest (MOI) was used following admission to the palliative care unit (PCU) of Eastern Health. The clinical notes of those included were reviewed to further describe the clinical details surrounding the use of the MOI. RESULTS Forty patients were included. Midazolam was the most common medication used (57.5%). The most common dual agent combination was midazolam plus levomepromazine. CONCLUSIONS This audit is the first description of pharmacological management of severe hyperactive delirium at the end of life requiring sedation in an Australian PCU.
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Affiliation(s)
- Kathryn Tham
- Supportive and Palliative Care Service, Wantirna Health, Wantirna, VIC, Australia.,Eastern Health Clinical School, Monash University, Melbourne, VIC, Australia
| | - Angela Shiu
- Supportive and Palliative Care Service, Wantirna Health, Wantirna, VIC, Australia .,Pharmacy Department, Eastern Health, Wantirna, VIC, Australia
| | - Leeroy William
- Supportive and Palliative Care Service, Wantirna Health, Wantirna, VIC, Australia.,Eastern Health Clinical School, Monash University, Melbourne, VIC, Australia.,Public Health Palliative Care Unit, Latrobe University, Melbourne, VIC, Australia
| | - Grace Walpole
- Supportive and Palliative Care Service, Wantirna Health, Wantirna, VIC, Australia.,Eastern Health Clinical School, Monash University, Melbourne, VIC, Australia
| | - Saly Rashed
- Supportive and Palliative Care Service, Wantirna Health, Wantirna, VIC, Australia.,Pharmacy Department, Eastern Health, Wantirna, VIC, Australia
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Association among rescue neuroleptic use, agitation, and perceived comfort: secondary analysis of a randomized clinical trial on agitated delirium. Support Care Cancer 2021; 29:7887-7894. [PMID: 34184130 DOI: 10.1007/s00520-021-06384-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2021] [Accepted: 06/21/2021] [Indexed: 10/21/2022]
Abstract
BACKGROUND Few studies have examined how the use of rescue medications could be used to inform on the efficacy of interventions in delirium clinical trials. The objective of this study was to determine the association among rescue medication use, Richmond Agitation-Sedation Scale (RASS), and perceived comfort by the nurses and caregivers. METHODS This was a pre-planned secondary analysis of a double-blind, randomized clinical trial comparing the use of a single dose of lorazepam plus haloperidol versus placebo plus haloperidol in patients with agitated delirium. Rescue medications were considered the gold standard for this analysis. The optimal cutoff for RASS analysis was calculated by using general linear regression models and determining the area of the curve and using the top left approach. We used 2 × 2 tables to examine the association between rescue medication use and perceived comfort. RESULTS Fifty-eight patients received the study medications and 52 (89%) completed the 8-h observation period. There were 26 (50%) patients in each arm. The lorazepam/haloperidol arm required fewer rescue doses (4/26 (15%)) vs. 16/26 (62%), p = 0.004). Patients with a greater initial RASS reduction required fewer rescue doses. The cutoff value for RASS improvement was 4 points, area under the curve (AUC) 0.64 (95% CI 0.49-0.79) for those who required no rescue doses, and 3 points, AUC 0.74 (95% CI 0.52-0.96) for those who required more than one rescue dose. CONCLUSIONS Rescue medication use was responsive to change and associated with both RASS scores and perceived patient comfort by the nurse and caregiver.
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Featherstone I, Hosie A, Siddiqi N, Grassau P, Bush SH, Taylor J, Sheldon T, Johnson MJ. The experience of delirium in palliative care settings for patients, family, clinicians and volunteers: A qualitative systematic review and thematic synthesis. Palliat Med 2021; 35:988-1004. [PMID: 33784915 PMCID: PMC8189008 DOI: 10.1177/02692163211006313] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
BACKGROUND Delirium is common in palliative care settings and is distressing for patients, their families and clinicians. To develop effective interventions, we need first to understand current delirium care in this setting. AIM To understand patient, family, clinicians' and volunteers' experience of delirium and its care in palliative care contexts. DESIGN Qualitative systematic review and thematic synthesis (PROSPERO 2018 CRD42018102417). DATA SOURCES The following databases were searched: CINAHL, Cochrane Database of Systematic Reviews, Database of Abstracts of Reviews of Effects, Embase, MEDLINE and PsycINFO (2000-2020) for qualitative studies exploring experiences of delirium or its care in specialist palliative care services. Study selection and quality appraisal were independently conducted by two reviewers. RESULTS A total of 21 papers describing 16 studies were included. In quality appraisal, trustworthiness (rigour of methods used) was assessed as high (n = 5), medium (n = 8) or low (n = 3). Three major themes were identified: interpretations of delirium and their influence on care; clinicians' responses to the suffering of patients with delirium and the roles of the family in delirium care. Nursing staff and other clinicians had limited understanding of delirium as a medical condition with potentially modifiable causes. Practice focused on alleviating patient suffering through person-centred approaches, which could be challenging with delirious patients, and medication use. Treatment decisions were also influenced by the distress of family and clinicians and resource limitations. Family played vital roles in delirium care. CONCLUSIONS Increased understanding of non-pharmacological approaches to delirium prevention and management, as well as support for clinicians and families, are important to enable patients' multi-dimensional needs to be met.
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Affiliation(s)
| | - Annmarie Hosie
- School of Nursing, The University of Notre Dame Australia, Sydney, NSW, Australia
- The Cunningham Centre for Palliative Care, St Vincent’s Health Network, Sydney, NSW, Australia
| | - Najma Siddiqi
- Department of Health Sciences, University of York, York, UK
- Hull York Medical School, University of York, York, UK
| | - Pamela Grassau
- School of Social Work, Carleton University, Ottawa, ON, Canada
- Department of Medicine, Division of Palliative Care, University of Ottawa, Ottawa, ON, Canada
- Bruyere Research Institute, Ottawa, ON, Canada
| | - Shirley H Bush
- Department of Medicine, Division of Palliative Care, University of Ottawa, Ottawa, ON, Canada
- Bruyere Research Institute, Ottawa, ON, Canada
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, ON, Canada
- Department of Palliative Care, Bruyere Continuing Care, Ottawa, ON, Canada
| | - Johanna Taylor
- Department of Health Sciences, University of York, York, UK
| | - Trevor Sheldon
- Institute of Population Health Sciences, Barts and the London School of Medicine and Dentistry, Queen Mary University of London, London, UK
| | - Miriam J Johnson
- Wolfson Palliative Care Research Centre, Hull York Medical School, University of Hull, Hull, UK
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Matsuda Y, Tanimukai H, Inoue S, Inada S, Sugano K, Hasuo H, Yoshimura M, Wada S, Dotani C, Adachi H, Okamoto Y, Takeuchi M, Fujisawa D, Kako J, Sasaki C, Kishi Y, Akizuki N, Inagaki M, Uchitomi Y, Matsushima E, Okuyama T. JPOS/JASCC clinical guidelines for delirium in adult cancer patients: a summary of recommendation statements. Jpn J Clin Oncol 2020; 50:586-593. [PMID: 32215557 PMCID: PMC7202141 DOI: 10.1093/jjco/hyaa003] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2019] [Revised: 12/30/2019] [Accepted: 01/08/2020] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND The Japanese Psycho-Oncology Society and Japanese Association of Supportive Care in Cancer recently launched the clinical practice guidelines for delirium in adult cancer patients. The aim of the guidelines was to provide evidence-based recommendations for the clinical assessment and management of delirium in cancer patients. This article reports the process of developing the guideline and summarizes the recommendations made. METHODS The guidelines were developed in accordance with the Medical Information Network Distribution Service creation procedures. The guideline development group, consisting of multidisciplinary members, formulated nine clinical questions. A systematic literature search was conducted to identify relevant articles published prior to through 31 May 2016. Each article was reviewed by two independent reviewers. The level of evidence and the strength of the recommendations were graded using the grading system developed by the Medical Information Network Distribution Service, following the concept of The Grading of Recommendations Assessment, Development and Evaluation system. The modified Delphi method was used to validate the recommendation statements. RESULTS This article provides a summary of the recommendations with rationales for each, as well as a short summary. CONCLUSIONS These guidelines will support the clinical assessment and management of delirium in cancer patients. However, additional clinical studies are warranted to further improve the management of delirium.
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Affiliation(s)
- Yoshinobu Matsuda
- Department of Psychosomatic Internal Medicine, National Hospital Organization Kinki-Chuo Chest Medical Center, Sakai, Japan
| | - Hitoshi Tanimukai
- Faculty of Human Health Sciences, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Shinichiro Inoue
- Department of Neuropsychiatry, Okayama University Graduate School of Medicine, Dentistry, and Pharmaceutical Science, Okayama, Japan
| | - Shuji Inada
- Department of Psychosomatic Medicine, The University of Tokyo Hospital, Tokyo, Japan
| | - Koji Sugano
- Division of Respiratory Medicine, Juntendo Tokyo Koto Geriatric Medical Center, Tokyo, Japan
| | - Hideaki Hasuo
- Department of Psychosomatic Medicine, Kansai Medical University, Hirakata, Japan
| | - Masafumi Yoshimura
- Department of Neuropsychiatry, Kansai Medical University, Moriguchi, Japan
| | - Saho Wada
- Department of Psycho-Oncology, National Cancer Center Hospital, Tokyo, Japan
| | - Chikako Dotani
- Department of Pediatrics, The University of Tokyo Hospital, Tokyo, Japan
| | | | - Yoshiaki Okamoto
- Department of Pharmacy, Ashiya Municipal Hospital, Ashiya, Japan
| | - Mari Takeuchi
- Department of Palliative Care, Keio University School of Medicine, Tokyo, Japan
| | - Daisuke Fujisawa
- Division of Patient Safety, Keio University School of Medicine, Tokyo, Japan
| | - Jun Kako
- Division of Nursing Science, Graduate School of Biomedical and Health Sciences, Hiroshima University, Hiroshima, Japan
| | - Chiyuki Sasaki
- Nursing Department, National Cancer Center Hospital, Tokyo, Japan
| | - Yasuhiro Kishi
- Department of Psychiatry, Nippon Medical School Musashikosugi Hospital, Kawasaki 211-8533, Japan
| | - Nobuya Akizuki
- Department of Psycho-Oncology/Psychiatry, Tokyo Metropolitan Cancer and Infectious Diseases Center Komagome Hospital, Tokyo 113-8677, Japan
| | - Masatoshi Inagaki
- Department of Psychiatry, Faculty of Medicine, Shimane University, Izumo 693-8501, Japan
| | - Yosuke Uchitomi
- Innovation Center for Supportive, Palliative and Psychosocial Care, National Cancer Center Hospital, Tokyo 104-0045, Japan
| | - Eisuke Matsushima
- Section of Liaison Psychiatry and Palliative Medicine, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University, Tokyo 113-8519, Japan
| | - Toru Okuyama
- Division of Psycho-oncology and Palliative Care, Nagoya City University Hospital, Mizuho-cho, Mizuho-ku, Nagoya, Aichi 467-8601, Japan
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13
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Shrestha P, Fick DM. Family caregiver's experience of caring for an older adult with delirium: A systematic review. Int J Older People Nurs 2020; 15:e12321. [PMID: 32374518 DOI: 10.1111/opn.12321] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2019] [Revised: 04/01/2020] [Accepted: 04/07/2020] [Indexed: 01/05/2023]
Abstract
AIM To enhance understanding of how family caregivers perceive the experience of caring for an older adult with delirium across care settings and to identify the challenges in recognising and managing delirium to inform future research and best practices. METHOD A systematic literature review was conducted in five databases per the Preferred Reporting Items for Systematic Reviews and Meta-Analyses criteria. Primary or secondary peer-reviewed articles published between 1987 and October 2018 describing the experiences of family caregivers caring for older adults with delirium or delirium superimposed on dementia were included in the review. Mixed Method Appraisal Tool (MMAT) was used to evaluate the methodological quality. A thematic synthesis of results was conducted to extract relevant data as per the aims of the study. RESULTS Eighteen articles met the eligibility criteria, which were reviewed and analysed in regard to purpose, sample, research design, variables and results. Seven themes emerged in the process. The current challenges and gaps in our knowledge of this phenomenon have also been highlighted, which should be helpful to inform best practices, and finally, an agenda for future research is proposed. CONCLUSION Family caregivers are an important partner in the detection and management of delirium. The impact of caring for an older adult with delirium on the family caregivers should not be overlooked. This paper highlights the dearth of research on family caregiver's experience of caring for older adults with delirium and even less in the context of delirium superimposed on dementia. More research is required to further understand the family caregiver's experience and their challenges in order to support them in their caregiving role and to determine their needs and preferences of being involved in the plan of care. IMPLICATIONS FOR PRACTICE These findings suggest that family caregivers are a valuable resource in the recognition and management of delirium and should be included as care partners in the health care team, while also catering to their health and well-being in the process.
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Affiliation(s)
| | - Donna M Fick
- Penn State College of Nursing, State College, PA, USA
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14
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Abstract
Delirium is highly prevalent in people with advanced life limiting illness(es), and current evidence can inform how we provide best delirium care in this setting. Whilst strategies to prevent and reverse delirium are the cornerstones of optimal care, the care for delirious patients who are approaching the end of life and their families pose specific challenges particularly if delirium is refractory flagging a grave prognosis. These include addressing additional supportive care needs, clinical decision-making about the degree of investigation and intervention, minimising distress from the symptoms of delirium itself and considering other concurrent problems contributing to agitation. A fine balance is needed to address other symptoms such as pain whilst minimizing psychoactive medication load. There is need for regular and clear information and communication about prognosis and goals of care. Witnessing a delirium episode in a loved one in close proximity to death requires consideration of the needs of the family into bereavement care. Palliative care is person and family-centred care provided for a person with an active, progressive, advanced disease; who has little or no prospect of cure and who is expected to die, and for whom the primary treatment goal is to optimise quality of life. It is an approach which can be provided regardless of setting and diagnosis, and by both specialist palliative care teams and other health professionals.
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Affiliation(s)
- Meera R Agar
- IMPACCT (Improving Palliative, Aged and Chronic Care Through Clinical Research and Translation) Faculty of Health, University of Technology Sydney, Sydney, Australia
- South West Sydney Clinical School, University of New South Wales, Sydney, Australia
- Ingham Institute for Applied Medical Research, Sydney, Australia
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15
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Meilak C, Biswell E, Willis R, Partridge J, Dhesi J. A qualitative exploration of the views of patients and their relatives regarding interventions to minimize the distress related to postoperative delirium. Int J Geriatr Psychiatry 2020; 35:230-249. [PMID: 31762082 DOI: 10.1002/gps.5241] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/20/2019] [Accepted: 11/07/2019] [Indexed: 11/05/2022]
Abstract
BACKGROUND Postoperative delirium (POD) is common in older people and can be distressing for patients and their relatives. This study aimed to describe the experience of postoperative delirium and explore the views of patients and relatives in order to inform the codesign of an intervention to minimize distress related to postoperative delirium. METHODS Qualitative study using a thematic analysis of semistructured interviews in patients (n = 11) and relatives (n = 12) who experienced and witnessed POD, respectively. RESULTS Patients and relatives find POD distressing and desire information on the cause and consequences of delirium. This information should be delivered pre-emptively where possible for patients and relatives during the episode for relatives and in post episode follow up for patients and their families. Information should be provided in person by a health care professional who has experience in managing delirium, supplemented by written materials. In addition, participants suggested training to improve staff and public awareness of delirium. CONCLUSIONS This qualitative study showed that patients and relatives find delirium distressing, report the need for an intervention to minimize this distress, and enabled codesign of a pilot intervention. Refinement and evaluation of this intervention should form the next step in this program of work.
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Affiliation(s)
- Catherine Meilak
- Perioperative Medicine for Older People Undergoing Surgery (POPS), East Kent Hospitals University Foundation Trust, Kent, UK
| | - Elizabeth Biswell
- Perioperative Medicine for Older People Undergoing Surgery (POPS), Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - Rosalind Willis
- Centre for Research on Ageing, University of Southampton, UK
| | - Judith Partridge
- Perioperative Medicine for Older People Undergoing Surgery (POPS), Guy's and St Thomas' NHS Foundation Trust, London, UK.,Division of Primary Care and Public Health Sciences, Faculty of Life Sciences and Medicine, King's College London, London, UK
| | - Jugdeep Dhesi
- Perioperative Medicine for Older People Undergoing Surgery (POPS), Guy's and St Thomas' NHS Foundation Trust, London, UK.,Division of Primary Care and Public Health Sciences, Faculty of Life Sciences and Medicine, King's College London, London, UK
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16
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Williams ST, Dhesi JK, Partridge JSL. Distress in delirium: causes, assessment and management. Eur Geriatr Med 2019; 11:63-70. [DOI: 10.1007/s41999-019-00276-z] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2019] [Accepted: 11/25/2019] [Indexed: 11/25/2022]
Abstract
Abstract
Purpose
Delirium is a common clinical syndrome associated with increased physical and psychological morbidity, mortality, inpatient stay and healthcare costs. There is growing interest in understanding the delirium experience and its psychological impact, including distress, for patients and their relatives, carers and healthcare providers.
Methods
This narrative review focuses on distress in delirium (DID) with an emphasis on its effect on older patients. It draws on qualitative and quantitative research to describe patient and environmental risk factors and variations in DID across a number of clinical settings, including medical and surgical inpatient wards and end of life care. The article provides an overview of the available distress assessment tools, both for clinical and research practice, and outlines their use in the context of delirium. This review also outlines established and emerging management strategies, focusing primarily on prevention and limitation of distress in delirium.
Results
Both significant illness and delirium cause distress. Patients who recall the episode of delirium describe common experiential features of delirium and distress. Relatives who witness delirium also experience distress, at levels suggested to be greater than that experienced by patients themselves. DID results in long-term psychological sequelae that can last months and years. Preventative actions, such pre-episode educational information for patients and their families in those at risk may reduce distress and psychological morbidity.
Conclusions
Improving clinicians’ understanding of the experience and long term psychological harm of delirium will enable the development of targeted support and information to patients at risk of delirium, and their families or carers.
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17
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Predisposing and precipitating risk factors for delirium in palliative care patients. Palliat Support Care 2019; 18:437-446. [DOI: 10.1017/s1478951519000919] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
AbstractObjectiveDelirium is a common complication in palliative care patients, especially in the terminal phase of the illness. To date, evidence regarding risk factors and prognostic outcomes of delirium in this vulnerable population remains sparse.MethodIn this prospective observational cohort study at a tertiary care center, 410 palliative care patients were included. Simple and multiple logistic regression models were used to identify associations between predisposing and precipitating factors and delirium in palliative care patients.ResultsThe prevalence of delirium in this palliative care cohort was 55.9% and reached 93% in the terminally ill. Delirium was associated with prolonged hospitalization (p < 0.001), increased care requirements (p < 0.001) and health care costs (p < 0.001), requirement for institutionalization (OR 0.11; CI 0.069–0.171; p < 0.001), and increased mortality (OR 18.29; CI 8.918–37.530; p < 0.001). Predisposing factors for delirium were male gender (OR 2.19; CI 1.251–3.841; p < 0.01), frailty (OR 15.28; CI 5.885–39.665; p < 0.001), hearing (OR 3.52; CI 1.721–7.210; p < 0.001), visual impairment (OR 3.15; CI 1.765–5.607; p < 0.001), and neoplastic brain disease (OR 3.63; CI 1.033–12.771; p < 0.05). Precipitating factors for delirium were acute renal failure (OR 6.79; CI 1.062–43.405; p < 0.05) and pressure sores (OR 3.66; CI 1.102–12.149; p < 0.05).Significance of resultsOur study identified several predisposing and precipitating risk factors for delirium in palliative care patients, some of which can be targeted early and modified to reduce symptom burden.
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18
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Watt CL, Momoli F, Ansari MT, Sikora L, Bush SH, Hosie A, Kabir M, Rosenberg E, Kanji S, Lawlor PG. The incidence and prevalence of delirium across palliative care settings: A systematic review. Palliat Med 2019; 33:865-877. [PMID: 31184538 PMCID: PMC6691600 DOI: 10.1177/0269216319854944] [Citation(s) in RCA: 75] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
BACKGROUND Delirium is a common and distressing neurocognitive condition that frequently affects patients in palliative care settings and is often underdiagnosed. AIM Expanding on a 2013 review, this systematic review examines the incidence and prevalence of delirium across all palliative care settings. DESIGN This systematic review and meta-analyses were prospectively registered with PROSPERO and included a risk of bias assessment. DATA SOURCES Five electronic databases were examined for primary research studies published between 1980 and 2018. Studies on adult, non-intensive care and non-postoperative populations, either receiving or eligible to receive palliative care, underwent dual reviewer screening and data extraction. Studies using standardized delirium diagnostic criteria or valid assessment tools were included. RESULTS Following initial screening of 2596 records, and full-text screening of 153 papers, 42 studies were included. Patient populations diagnosed with predominantly cancer (n = 34) and mixed diagnoses (n = 8) were represented. Delirium point prevalence estimates were 4%-12% in the community, 9%-57% across hospital palliative care consultative services, and 6%-74% in inpatient palliative care units. The prevalence of delirium prior to death across all palliative care settings (n = 8) was 42%-88%. Pooled point prevalence on admission to inpatient palliative care units was 35% (confidence interval = 0.29-0.40, n = 14). Only one study had an overall low risk of bias. Varying delirium screening and diagnostic practices were used. CONCLUSION Delirium is prevalent across all palliative care settings, with one-third of patients delirious at the time of admission to inpatient palliative care. Study heterogeneity limits meta-analyses and highlights the future need for rigorous studies.
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Affiliation(s)
- Christine L Watt
- 1 Division of Palliative Care, Department of Medicine, University of Ottawa, Ottawa, ON, Canada.,2 Division of Palliative Care, Bruyère Continuing Care, Élisabeth Bruyère Hospital, Ottawa, ON, Canada
| | - Franco Momoli
- 3 Ottawa Hospital Research Institute, Ottawa, ON, Canada.,4 Children's Hospital of Eastern Ontario Research Institute, Ottawa, ON, Canada.,5 School of Epidemiology and Public Health, Faculty of Medicine, University of Ottawa, Ottawa, ON, Canada
| | - Mohammed T Ansari
- 5 School of Epidemiology and Public Health, Faculty of Medicine, University of Ottawa, Ottawa, ON, Canada
| | - Lindsey Sikora
- 6 Health Sciences Library, University of Ottawa, Ottawa, ON, Canada
| | - Shirley H Bush
- 1 Division of Palliative Care, Department of Medicine, University of Ottawa, Ottawa, ON, Canada.,2 Division of Palliative Care, Bruyère Continuing Care, Élisabeth Bruyère Hospital, Ottawa, ON, Canada.,3 Ottawa Hospital Research Institute, Ottawa, ON, Canada.,7 Bruyère Research Institute, Ottawa, ON, Canada
| | - Annmarie Hosie
- 8 IMPACCT, University of Technology Sydney, Ultimo, NSW, Australia
| | | | - Erin Rosenberg
- 9 Division of Critical Care, Department of Medicine, University of Ottawa, Ottawa, ON, Canada.,10 Department of Critical Care, The Ottawa Hospital, Ottawa, ON, Canada
| | - Salmaan Kanji
- 3 Ottawa Hospital Research Institute, Ottawa, ON, Canada.,11 Department of Pharmacy, The Ottawa Hospital, Ottawa, ON, Canada.,12 Faculty of Medicine, University of Ottawa, Ottawa, ON, Canada
| | - Peter G Lawlor
- 1 Division of Palliative Care, Department of Medicine, University of Ottawa, Ottawa, ON, Canada.,2 Division of Palliative Care, Bruyère Continuing Care, Élisabeth Bruyère Hospital, Ottawa, ON, Canada.,3 Ottawa Hospital Research Institute, Ottawa, ON, Canada.,7 Bruyère Research Institute, Ottawa, ON, Canada
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19
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Impact of an educational workshop upon psychiatrists' attitudes towards delirium care. Ir J Psychol Med 2019; 36:89-98. [PMID: 31187719 DOI: 10.1017/ipm.2016.47] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
OBJECTIVES Improving knowledge about delirium care is a key target for health care. We describe the implementation of a four-part workshop focusing upon key aspects of delirium care. METHODS Attitudes towards and understanding of delirium diagnosis and management amongst psychiatrists were surveyed before and immediately after an educational workshop. RESULTS There were 62 participants. Pre-workshop, delirium was rated highly relevant to psychiatry. Overall level of confidence in diagnosis was modest, with the behavioural and psychological symptoms of dementia considered the most challenging differential diagnosis. Only nine participants (15%) correctly identified DSM-5 delirium criteria. Preferred assessment of attention varied with six different approaches endorsed. Confidence was higher for managing hyperactive compared with hypoactive delirium (p<0.001). Pharmacotherapy was more frequently endorsed for hyperactive compared with hypoactive presentations, with haloperidol the most popular agent (p<0.001). A total of 41 (66%) participants completed post-workshop assessments. Post-workshop, there were significant increases to the perceived relevance of delirium (p = 0.003), confidence in overall diagnosis (p<0.001) accuracy of awareness of DSM-5 criteria (p<0.001), and confidence in treating different presentations (p<0.001). The Months Backward Test was the preferred bedside test of attention (38/40 respondents). CONCLUSIONS This interactive educational intervention impacted positively upon knowledge and attitudes amongst psychiatrists towards key aspects of delirium care. Further investigation can examine the impact upon longer term knowledge and behaviour.
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20
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Bohart S, Merete Møller A, Forsyth Herling S. Do health care professionals worry about delirium? Relatives' experience of delirium in the intensive care unit: A qualitative interview study. Intensive Crit Care Nurs 2019; 53:84-91. [PMID: 31079979 DOI: 10.1016/j.iccn.2019.04.010] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2019] [Revised: 03/19/2019] [Accepted: 04/28/2019] [Indexed: 10/26/2022]
Abstract
OBJECTIVES In intensive care units, there is a high incidence of delirium, which relates to the risk of complications. Engagement of relatives is an acknowledged part of handling delirium, but knowledge of relatives' perspectives is lacking. AIM To explore relatives' experiences of delirium in the critically ill patient admitted to an intensive care unit. RESEARCH DESIGN A qualitative design with a phenomenological approach. Semi-structured interviews with eleven relatives of critically ill patients who had delirium during admission to the intensive care unit. SETTING An intensive care unit in Denmark. FINDINGS Three categories emerged: 'Delirium is not the main concern', 'Communication with health-care professionals is crucial', and 'Delirium impacts on relatives'. Relatives had a lack of knowledge of delirium. Symptoms of delirium were thought of as a natural consequence of critical illness and seemed to be a secondary problem. Health-care professionals did not talk about delirium and information was requested. Delirium and the manifestation of it was experienced in different ways and brought different ways of coping. CONCLUSION Findings give a new insight into relatives' experience of delirium in the intensive care unit. Relatives need more information to better understand delirium. Future research must investigate the potential in helping relatives to cope with delirium, to the benefit of both patient and relatives.
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Affiliation(s)
- Søs Bohart
- Department of Anesthesiology, Herlev Hospital, University of Copenhagen, Herlev Ringvej 75, 2730 Herlev, Denmark; Department of Cardiology, Intensive Care Unit, 2143, Rigshospitalet, University of Copenhagen, Blegdamsvej 9, 2100 Copenhagen, Denmark.
| | - Ann Merete Møller
- Department of Anesthesiology, Herlev Hospital, University of Copenhagen, Herlev Ringvej 75, 2730 Herlev, Denmark.
| | - Suzanne Forsyth Herling
- The Neuroscience Centre, Rigshospitalet, University of Copenhagen, Blegdamsvej 9, 2100 Copenhagen, Denmark
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Bush SH, Tierney S, Lawlor PG. Clinical Assessment and Management of Delirium in the Palliative Care Setting. Drugs 2019; 77:1623-1643. [PMID: 28864877 PMCID: PMC5613058 DOI: 10.1007/s40265-017-0804-3] [Citation(s) in RCA: 77] [Impact Index Per Article: 15.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Delirium is a neurocognitive syndrome arising from acute global brain dysfunction, and is prevalent in up to 42% of patients admitted to palliative care inpatient units. The symptoms of delirium and its associated communicative impediment invariably generate high levels of patient and family distress. Furthermore, delirium is associated with significant patient morbidity and increased mortality in many patient populations, especially palliative care where refractory delirium is common in the dying phase. As the clinical diagnosis of delirium is frequently missed by the healthcare team, the case for regular screening is arguably very compelling. Depending on its precipitating factors, a delirium episode is often reversible, especially in the earlier stages of a life-threatening illness. Until recently, antipsychotics have played a pivotal role in delirium management, but this role now requires critical re-evaluation in light of recent research that failed to demonstrate their efficacy in mild- to moderate-severity delirium occurring in palliative care patients. Non-pharmacological strategies for the management of delirium play a fundamental role and should be optimized through the collective efforts of the whole interprofessional team. Refractory agitated delirium in the last days or weeks of life may require the use of pharmacological sedation to ameliorate the distress of patients, which is invariably juxtaposed with increasing distress of family members. Further evaluation of multicomponent strategies for delirium prevention and treatment in the palliative care patient population is urgently required.
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Affiliation(s)
- Shirley Harvey Bush
- Department of Medicine, University of Ottawa, Ottawa, ON, Canada. .,Bruyère Research Institute (BRI), Ottawa, ON, Canada. .,Ottawa Hospital Research Institute (OHRI), Ottawa, ON, Canada. .,Bruyère Continuing Care, 43 Bruyère Street, Ottawa, ON, K1N 5C8, Canada.
| | - Sallyanne Tierney
- Bruyère Continuing Care, 43 Bruyère Street, Ottawa, ON, K1N 5C8, Canada
| | - Peter Gerard Lawlor
- Department of Medicine, University of Ottawa, Ottawa, ON, Canada.,Bruyère Research Institute (BRI), Ottawa, ON, Canada.,Ottawa Hospital Research Institute (OHRI), Ottawa, ON, Canada.,Bruyère Continuing Care, 43 Bruyère Street, Ottawa, ON, K1N 5C8, Canada
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22
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Nishioka M, Okuyama T, Uchida M, Aiki S, Ito Y, Osaga S, Imai F, Akechi T. What is the appropriate communication style for family members confronting difficult surrogate decision-making in palliative care?: A randomized video vignette study in medical staff with working experiences of clinical oncology. Jpn J Clin Oncol 2019; 49:48-56. [PMID: 30508206 DOI: 10.1093/jjco/hyy178] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2018] [Accepted: 11/07/2018] [Indexed: 02/06/2023] Open
Abstract
Background The family members of terminally ill patients are often requested to make difficult surrogate decisions during palliative care. This study sought to clarify the appropriate communication style for physicians as perceived by family members confronting difficult surrogate decision-making. Methods This experimental psychological study used scripted videos. In the videos, the physician described treatment options including continuous deep sedation to the family members of patients with cancer and terminal delirium using an autonomous or paternalistic style. Medical professionals with clinical experience in oncology were randomly assigned to either group viewing the videos. The primary outcomes were physician compassion, decisional conflict and emotion scores. We also evaluated the communication style preference. Results In total, 251 participants completed this study. Although participants in both groups reported high physician compassion, participants in the autonomous style group reported lower compassion scores (reflecting higher physician compassion) (mean 15.0 vs. 17.3, P = 0.050), lower decisional conflicts scores (51.1 vs. 56.8, P = 0.002) and comparable emotions compared with those in the paternalistic style group. Seventy-six percent of participants preferred the autonomous style. Conclusions Regarding difficult surrogate decision-making, the autonomous style might be more appropriate than the paternalistic style. However, various factors, such as family members' communication style preferences, family members' values, physician-family relationships and ethnic cultures, should be considered.
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Affiliation(s)
- Masahiro Nishioka
- Department of Psychiatry and Cognitive-Behavioral Medicine, Nagoya City University Graduate School of Medical Sciences, Mizuho-cho, Mizuho-ku, Nagoya, Aichi, Japan.,Division of Psycho-oncology and Palliative Care, Nagoya City University Hospital, Mizuho-cho, Mizuho-ku, Nagoya, Aichi, Japan
| | - Toru Okuyama
- Department of Psychiatry and Cognitive-Behavioral Medicine, Nagoya City University Graduate School of Medical Sciences, Mizuho-cho, Mizuho-ku, Nagoya, Aichi, Japan.,Division of Psycho-oncology and Palliative Care, Nagoya City University Hospital, Mizuho-cho, Mizuho-ku, Nagoya, Aichi, Japan
| | - Megumi Uchida
- Department of Psychiatry and Cognitive-Behavioral Medicine, Nagoya City University Graduate School of Medical Sciences, Mizuho-cho, Mizuho-ku, Nagoya, Aichi, Japan.,Division of Psycho-oncology and Palliative Care, Nagoya City University Hospital, Mizuho-cho, Mizuho-ku, Nagoya, Aichi, Japan
| | - Sayo Aiki
- Division of Psycho-oncology and Palliative Care, Nagoya City University Hospital, Mizuho-cho, Mizuho-ku, Nagoya, Aichi, Japan.,Department of Palliative Care, National Hospital Organization Osaka National Hospital, 2-1-14, Hoenzaka, Chuo-ku, Osaka, Japan.,Department of Palliative Medicine, Higashi-Osaka Hospital, Chuo, Joto-ku, Osaka, Japan
| | - Yoshinori Ito
- Division of Psycho-oncology and Palliative Care, Nagoya City University Hospital, Mizuho-cho, Mizuho-ku, Nagoya, Aichi, Japan
| | - Satoshi Osaga
- Clinical Research Management Center, Nagoya City University Hospital, Mizuho-cho, Mizuho-ku, Nagoya, Aichi, Japan
| | - Fuminobu Imai
- Department of Psychiatry and Cognitive-Behavioral Medicine, Nagoya City University Graduate School of Medical Sciences, Mizuho-cho, Mizuho-ku, Nagoya, Aichi, Japan.,Division of Psycho-oncology and Palliative Care, Nagoya City University Hospital, Mizuho-cho, Mizuho-ku, Nagoya, Aichi, Japan
| | - Tatsuo Akechi
- Department of Psychiatry and Cognitive-Behavioral Medicine, Nagoya City University Graduate School of Medical Sciences, Mizuho-cho, Mizuho-ku, Nagoya, Aichi, Japan.,Division of Psycho-oncology and Palliative Care, Nagoya City University Hospital, Mizuho-cho, Mizuho-ku, Nagoya, Aichi, Japan
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23
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Cohen MZ, Pace EA, Kaur G, Bruera E. Delirium in Advanced Cancer Leading to Distress in Patients and Family Caregivers. J Palliat Care 2018. [DOI: 10.1177/082585970902500303] [Citation(s) in RCA: 62] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Background: Information is limited about the experiences of delirium among patients with advanced cancer and their caregivers, which makes designing interventions to relieve delirium-related distress difficult. To better understand the experience and thus permit the design of effective interventions, we collected and analyzed data from patients with advanced cancer who had recovered from delirium and their family caregivers. Method: Phenomenolog-ical interviews were conducted separately with 37 caregivers and 34 patients. One investigator reviewed verbatim transcripts of the audio-taped interviews to identify themes, which the research team confirmed. Results: Most patients and all caregivers had vivid memories of the experience; their descriptions were consistent. Most also attributed the confusion to pain medication. Caregivers had concerns about how best to help patients, patients’ imminent deaths, and their own well-being. Conclusions: The main finding that delirium leads to distress for both patients and care-givers indicates the importance of recognizing, treating, and, if possible, preventing delirium in this population. Concerns about pain medications also indicate the need to educate patients and caregivers about symptom management. Caregivers also need emotional support.
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Affiliation(s)
- Marlene Z. Cohen
- College of Nursing, University of Nebraska Medical Center, Omaha, Nebraska, USA
| | - Ellen A. Pace
- Quintiles Transnational Corporation, Austin, Texas, USA
| | - Guddi Kaur
- Anderson Cancer Center, University of Texas, Houston, Texas, USA
| | - Eduardo Bruera
- Anderson Cancer Center, University of Texas, Houston, Texas, USA
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Meagher D, Agar MR, Teodorczuk A. Debate article: Antipsychotic medications are clinically useful for the treatment of delirium. Int J Geriatr Psychiatry 2018; 33:1420-1427. [PMID: 28758323 DOI: 10.1002/gps.4759] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/15/2017] [Accepted: 06/01/2017] [Indexed: 11/05/2022]
Abstract
Prescribing of antipsychotic medications for patients with delirium remains controversial. Concerns exist that these vulnerable and frail patients may be prescribed antipsychotics inappropriately as a substitute for non-pharmacological approaches when identifiable causes are not found or they challenge ward processes. Moreover, recent evidence suggests that antipsychotics may cause more harm than good in the palliative care patient group with delirium. On the other hand, guidelines in the United Kingdom and the Netherlands support prescribing of antipsychotics in certain circumstances, and a large European survey has revealed that antipsychotics tend to be prescribed first line for hyperactive delirium. Never before, therefore, is there a greater need to examine whether indeed these medications are clinically useful for the treatment of delirium. With this in mind, evidence-based arguments for and against prescribing antipsychotics for the treatment of delirium are presented in this debate article. The paper concludes with a moderation piece to help guide clinical practice.
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Affiliation(s)
- David Meagher
- Cognitive Impairment Research Group, Graduate Entry Medical School, University of Limerick, Ireland.,Department of Psychiatry, University Hospital Limerick, Ireland
| | - Meera R Agar
- Faculty of Health, University of Technology Sydney, New South Wales, Australia.,South West Sydney Clinical School, University of New South Wales, New South Wales, Australia.,Ingham Institute of Applied Medical Research, New South Wales, Australia.,Discipline, Palliative and Supportive Services, Flinders University, South Australia, Australia
| | - Andrew Teodorczuk
- School of Medicine, Griffith University, Gold Coast, Australia.,Health Institute for the Development of Education and Scholarship (Health IDEAS), Griffith University, Queensland, Australia
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Bush SH, Lawlor PG, Ryan K, Centeno C, Lucchesi M, Kanji S, Siddiqi N, Morandi A, Davis DHJ, Laurent M, Schofield N, Barallat E, Ripamonti CI. Delirium in adult cancer patients: ESMO Clinical Practice Guidelines. Ann Oncol 2018; 29:iv143-iv165. [PMID: 29992308 DOI: 10.1093/annonc/mdy147] [Citation(s) in RCA: 86] [Impact Index Per Article: 14.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023] Open
Affiliation(s)
- S H Bush
- Division of Palliative Care, Department of Medicine, University of Ottawa, Ottawa
- Ottawa Hospital Research Institute, Ottawa
- Bruyère Research Institute, Ottawa
- Bruyère Continuing Care, Ottawa, Canada
| | - P G Lawlor
- Division of Palliative Care, Department of Medicine, University of Ottawa, Ottawa
- Ottawa Hospital Research Institute, Ottawa
- Bruyère Research Institute, Ottawa
- Bruyère Continuing Care, Ottawa, Canada
| | - K Ryan
- Department of Palliative Medicine, Mater Misericordiae University Hospital, Dublin
- St Francis Hospice, Dublin
- School of Medicine, University College, Dublin, Ireland
| | - C Centeno
- Department of Palliative Medicine, University of Navarra Hospital, Pamplona
- Palliative Medicine Group, Oncology Area, Navarra Institute for Health Research IdiSNA, Pamplona
- ATLANTES Research Program, Institute for Culture and Society (ICS), University of Navarra, Pamplona, Spain
| | - M Lucchesi
- Division of Thoracic Oncology, Cardio-Thoracic Department, University Hospital of Pisa, Pisa, Italy
| | - S Kanji
- Ottawa Hospital Research Institute, Ottawa
- Department of Pharmacy, The Ottawa Hospital, Ottawa, Canada
| | - N Siddiqi
- Department of Health Sciences, Hull York Medical School, University of York, York
- Bradford District Care NHS Foundation Trust, Bradford, UK
| | - A Morandi
- Department of Rehabilitation, Aged Care Unit, Ancelle Hospital, Cremona, Italy
| | - D H J Davis
- MRC Unit for Lifelong Health and Ageing at University College London, London, UK
| | - M Laurent
- Internal Medicine and Geriatric Department, APHP, Henri-Mondor Hospital, Créteil
- University Paris Est (UPE), UPEC A-TVB DHU, CEpiA (Clinical Epidemiology and Aging) Unit EA 7376, Créteil, France
| | | | - E Barallat
- Faculty of Nursing, Department of Nursing and Physiotherapy, University of Lleida, Lleida, Spain
| | - C I Ripamonti
- Department of Onco-Haematology Fondazione IRCCS, Istituto Nazionale dei Tumori, Milano, Italy
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Martins S, Pinho E, Correia R, Moreira E, Lopes L, Paiva JA, Azevedo L, Fernandes L. What effect does delirium have on family and nurses of older adult patients? Aging Ment Health 2018; 22:903-911. [PMID: 29103316 DOI: 10.1080/13607863.2017.1393794] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
OBJECTIVES This study aims to analyse the level of distress caused by delirium in patients' family and their nurses, and to identify factors associated with psychological distress in families of older adult inpatients in Intermediate Care Units/IMCUs regarding their global experience during hospitalization. METHOD A prospective pilot study was carried out with families and nurses of older adult patients (≥65 y.o.) consecutively recruited from two IMCUs in Intensive Care Medicine Service in a University Hospital. Patients with Glasgow Coma Scale ≤11, brain injury, blindness/deafness and inability to communicate were excluded. Delirium was daily assessed with Confusion Assessment Method/CAM. The distress level regarding this episode in family and nurses was measured with Delirium Experience Questionnaire/DEQ. Family psychological distress of all recruited patients was assessed with Kessler Psychological Distress Scale/K10. RESULTS This study included 42 inpatients (mean age/MA = 78 y.o., 50% women), 32 families (68.8% sons/daughters, MA = 50.6 y.o., 81.3% women) and 12 nurses caring for delirium patients (MA = 33 y.o., all women). A total of 12 (28.6%) patients had delirium. Distress related to this episode were higher for families than for nurses (M = 3 vs. M = 2), but differences did not reach statistical significance (Z = -1.535, p = 0.125). The hierarchical regression model explained 44.3% of variability in family psychological distress. Higher levels of psychological distress were associated with living with the patient (p = 0.029), presence of previous cognitive decline (p = 0.048) and development of delirium (p = 0.010). CONCLUSION These preliminary results show that family psychological distress is higher, when older adult patients developed delirium during hospitalization. Particular attention to these family carers should be given in future development of psychological support and psychoeducational interventions.
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Affiliation(s)
- Sónia Martins
- a Center For Health Technology and Services Research/CINTESIS , Porto , Portugal.,b Department of Clinical Neurosciences and Mental Health, Faculty of Medicine , University of Porto , Porto , Portugal
| | - Elika Pinho
- c Intensive Care Medicine Department , Centro Hospitalar São João/CHSJ , Porto , Portugal
| | - Raquel Correia
- c Intensive Care Medicine Department , Centro Hospitalar São João/CHSJ , Porto , Portugal
| | - Emília Moreira
- a Center For Health Technology and Services Research/CINTESIS , Porto , Portugal
| | - Luís Lopes
- c Intensive Care Medicine Department , Centro Hospitalar São João/CHSJ , Porto , Portugal
| | - José Artur Paiva
- c Intensive Care Medicine Department , Centro Hospitalar São João/CHSJ , Porto , Portugal.,d Department of Medicine , Faculty of Medicine , University of Porto , Porto , Portugal
| | - Luís Azevedo
- a Center For Health Technology and Services Research/CINTESIS , Porto , Portugal.,e Department of Community Medicine, Information and Health Decision Sciences/MEDCIDS, Faculty of Medicine , University of Porto , Porto , Portugal
| | - Lia Fernandes
- a Center For Health Technology and Services Research/CINTESIS , Porto , Portugal.,b Department of Clinical Neurosciences and Mental Health, Faculty of Medicine , University of Porto , Porto , Portugal.,f Clinic of Psychiatry and Mental Health , CHSJ , Porto , Portugal
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Jeong E, Chang SO. Exploring nurses' recognition of delirium in the elderly by using Q-methodology. Jpn J Nurs Sci 2017; 15:298-308. [PMID: 29266727 DOI: 10.1111/jjns.12199] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2017] [Revised: 08/31/2017] [Accepted: 10/01/2017] [Indexed: 01/28/2023]
Abstract
AIM Despite its high prevalence and seriousness, delirium has been underrecognized by nurses. One reason is that the original characteristics of delirium are relatively unspecific and phenomenologically diverse, which makes a nurse's subjective decision more important in delirium detection. This study aims to identify the experiences, practices, and viewpoints of nurses in recognizing delirium in the elderly. METHODS In this study, Q-methodology, which is a method for analyzing subjectivity, was used. Following the steps of Q-methodology, 32 nurses with experiences in caring for the delirious elderly sorted 34 Q-statements into the shape of a normal distribution. A centroid factor analysis and varimax rotation using the PQMethod program were conducted. RESULTS This study revealed four factors regarding nurses toward delirium recognition in the elderly. They were: Factor I, prediction from the integrated signs; Factor II, visible symptom-centered detection; Factor III, the detection of abnormal changes based on concentrated observation; and Factor IV, identification by relying on the diagnostic data. CONCLUSION The result of the study can help to understand elderly delirium detection more practically from a nurse's point of view. It is expected to be used as a basis for a practical and accessible delirium education for nurses that reflects nurses' subjective viewpoints.
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Affiliation(s)
- Eunhye Jeong
- Nursing Department, College of Nursing, Korea University, Seoul, South Korea
| | - Sung Ok Chang
- Nursing Department, College of Nursing, Korea University, Seoul, South Korea
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28
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Bush SH, Tierney S, Lawlor PG. Clinical Assessment and Management of Delirium in the Palliative Care Setting. Drugs 2017. [PMID: 28864877 DOI: 10.1007/s40265‐017‐0804‐3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Delirium is a neurocognitive syndrome arising from acute global brain dysfunction, and is prevalent in up to 42% of patients admitted to palliative care inpatient units. The symptoms of delirium and its associated communicative impediment invariably generate high levels of patient and family distress. Furthermore, delirium is associated with significant patient morbidity and increased mortality in many patient populations, especially palliative care where refractory delirium is common in the dying phase. As the clinical diagnosis of delirium is frequently missed by the healthcare team, the case for regular screening is arguably very compelling. Depending on its precipitating factors, a delirium episode is often reversible, especially in the earlier stages of a life-threatening illness. Until recently, antipsychotics have played a pivotal role in delirium management, but this role now requires critical re-evaluation in light of recent research that failed to demonstrate their efficacy in mild- to moderate-severity delirium occurring in palliative care patients. Non-pharmacological strategies for the management of delirium play a fundamental role and should be optimized through the collective efforts of the whole interprofessional team. Refractory agitated delirium in the last days or weeks of life may require the use of pharmacological sedation to ameliorate the distress of patients, which is invariably juxtaposed with increasing distress of family members. Further evaluation of multicomponent strategies for delirium prevention and treatment in the palliative care patient population is urgently required.
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Affiliation(s)
- Shirley Harvey Bush
- Department of Medicine, University of Ottawa, Ottawa, ON, Canada. .,Bruyère Research Institute (BRI), Ottawa, ON, Canada. .,Ottawa Hospital Research Institute (OHRI), Ottawa, ON, Canada. .,Bruyère Continuing Care, 43 Bruyère Street, Ottawa, ON, K1N 5C8, Canada.
| | - Sallyanne Tierney
- Bruyère Continuing Care, 43 Bruyère Street, Ottawa, ON, K1N 5C8, Canada
| | - Peter Gerard Lawlor
- Department of Medicine, University of Ottawa, Ottawa, ON, Canada.,Bruyère Research Institute (BRI), Ottawa, ON, Canada.,Ottawa Hospital Research Institute (OHRI), Ottawa, ON, Canada.,Bruyère Continuing Care, 43 Bruyère Street, Ottawa, ON, K1N 5C8, Canada
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Lawley H, Hewison A. An integrative literature review exploring the clinical management of delirium in patients with advanced cancer. J Clin Nurs 2017; 26:4172-4183. [DOI: 10.1111/jocn.13960] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/03/2017] [Indexed: 11/28/2022]
Affiliation(s)
- Hayley Lawley
- Ward 622; Queen Elizabeth Hospital Birmingham; Birmingham UK
| | - Alistair Hewison
- University of Birmingham-School of Health Sciences; Birmingham UK
- The University of Birmingham; Birmingham UK
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Tursunov O, Cherny NI, Ganz FD. Experiences of Family Members of Dying Patients Receiving Palliative Sedation. Oncol Nurs Forum 2016; 43:E226-E232. [PMID: 27768142 DOI: 10.1188/16.onf.e226-e232] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
PURPOSE/OBJECTIVES To describe the experience of family members of patients receiving palliative sedation at the initiation of treatment and after the patient has died and to compare these experiences over time.
. DESIGN Descriptive comparative study.
. SETTING Oncology ward at Shaare Zedek Medical Center in Jerusalem, Israel.
. SAMPLE A convenience sample of 34 family members of dying patients receiving palliative sedation.
. METHODS A modified version of a questionnaire describing experiences of family members with palliative sedation was administered during palliative sedation and one to four months after the patient died. Descriptive statistics were used to describe the results of the questionnaire, and appropriate statistical analyses were conducted for comparisons over time.
. MAIN RESEARCH VARIABLES Experiences of family members and time.
. FINDINGS Most relatives were satisfied with the sedation and staff support. Palliative sedation was experienced as an ethical way to relieve suffering. However, one-third felt that it shortened the patient's life. An explanation of the treatment was given less than half of the time and was usually given on the same day treatment was started. This explanation was given by physicians and nurses. Many felt that they were not ready for changes in the patient's condition and wanted increased opportunities to discuss the treatment with oncology care providers. No statistically significant differences in experiences were found over time.
. CONCLUSIONS Relatives' experiences of palliative sedation were generally positive and stable over time. Important experiences included timing of the initiation of sedation, timing and quality of explanations, and communication.
. IMPLICATIONS FOR NURSING Nurses should attempt to initiate discussions of the possible role of sedation in the event of refractory symptoms and follow through with continued discussions. The management of refractory symptoms at the end of life, the role of sedation, and communication skills associated with decision making related to palliative sedation should be a part of the core nursing curriculum. Nursing administrators in areas that use palliative sedation should enforce good nursing clinical practice as recommended by international practice guidelines, such as those of the European Association for Palliative Care.
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Affiliation(s)
| | | | - Freda DeKeyser Ganz
- Director of the clinical masters program, Henrietta Szold Hadassah Medical Organization, Jerusalem, Israel
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Morita T, Naito AS, Aoyama M, Ogawa A, Aizawa I, Morooka R, Kawahara M, Kizawa Y, Shima Y, Tsuneto S, Miyashita M. Nationwide Japanese Survey About Deathbed Visions: "My Deceased Mother Took Me to Heaven". J Pain Symptom Manage 2016; 52:646-654.e5. [PMID: 27660082 DOI: 10.1016/j.jpainsymman.2016.04.013] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/25/2015] [Revised: 02/17/2016] [Accepted: 04/29/2016] [Indexed: 11/29/2022]
Abstract
OBJECTIVES Primary aim was to clarify the prevalence and factors associated with the occurrence of deathbed visions, explore associations among deathbed visions, a good death, and family depression. Additional aim was to explore the emotional reaction, perception, and preferred clinical practice regarding deathbed visions from the view of bereaved family members. METHODS A nationwide questionnaire survey was conducted involving 3964 family members of cancer patients who died at hospitals, palliative care units, and home. RESULTS A total of 2827 responses (71%) were obtained, and finally 2221 responses were analyzed. Deathbed visions were reported in 21% (95% CIs, 19-23; n = 463). Deathbed visions were significantly more likely to be observed in older patients, female patients, female family members, family members other than spouses, more religious families, and families who believed that the soul survives the body after death. Good death scores for the patients were not significantly different between the families who reported that the patients had experienced deathbed visions and those who did not, whereas depression was more frequently observed in the former than latter, with marginal significance (20 vs. 16%, respectively, adjusted P = 0.068). Although 35% of the respondents agreed that deathbed visions were hallucinations, 38% agreed that such visions were a natural and transpersonal phenomenon in the dying process; 81% regarded it as necessary or very necessary for clinicians to share the phenomenon neutrally, not automatically labeling them as medically abnormal. CONCLUSIONS Deathbed vision is not an uncommon phenomenon. Clinicians should not automatically regard such visions as an abnormal phenomenon to be medically treated and rather provide an individualized approach.
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Affiliation(s)
- Tatsuya Morita
- Department of Palliative and Supportive Care, Palliative Care Team, Seirei Mikatahara General Hospital, Hamamatsu, Shizuoka, Japan.
| | - Akemi Shirado Naito
- Palliative Care Team, Seirei Mikatahara General Hospital, Hamamatsu, Shizuoka, Japan
| | - Maho Aoyama
- Department of Palliative Nursing, Health Sciences, Tohoku University Graduate School of Medicine, Sendai, Miyagi, Japan
| | - Asao Ogawa
- Psycho-Oncology Division, Research Center for Innovative Oncology, National Cancer Center Hospital East, Kashiwa, Chiba, Japan
| | - Izuru Aizawa
- Soshukai Research Institute, Natori, Miyagi, Japan
| | - Ryosuke Morooka
- Faculty of Education, Shimane University, Matsue, Shimane, Japan
| | | | - Yoshiyuki Kizawa
- Department of Palliative Medicine, Kobe University Graduate School of Medicine, Kobe, Hyogo, Japan
| | - Yasuo Shima
- Department of Palliative Medicine, Tsukuba Medical Center Foundation, Home Care Service, Tsukuba Medical Center Hospital, Tsukuba, Ibaraki, Japan
| | - Satoru Tsuneto
- Department of Palliative Medicine, Palliative Care Center, Kyoto University Hospital, Sakyo-ku, Kyoto, Japan
| | - Mitsunori Miyashita
- Department of Palliative Nursing, Health Sciences, Tohoku University Graduate School of Medicine, Sendai, Miyagi, Japan
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Finucane AM, Lugton J, Kennedy C, Spiller JA. The experiences of caregivers of patients with delirium, and their role in its management in palliative care settings: an integrative literature review. Psychooncology 2016; 26:291-300. [PMID: 27132588 PMCID: PMC5363350 DOI: 10.1002/pon.4140] [Citation(s) in RCA: 78] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2015] [Revised: 03/07/2016] [Accepted: 03/25/2016] [Indexed: 01/15/2023]
Abstract
OBJECTIVES To explore the experiences of caregivers of terminally ill patients with delirium, to determine the potential role of caregivers in the management of delirium at the end of life, to identify the support required to improve caregiver experience and to help the caregiver support the patient. METHODS Four electronic databases were searched-PsychInfo, Medline, Cinahl and Scopus from January 2000 to July 2015 using the terms 'delirium', 'terminal restlessness' or 'agitated restlessness' combined with 'carer' or 'caregiver' or 'family' or 'families'. Thirty-three papers met the inclusion criteria and remained in the final review. RESULTS Papers focused on (i) caregiver experience-distress, deteriorating relationships, balancing the need to relieve suffering with desire to communicate and helplessness versus control; (ii) the caregiver role-detection and prevention of delirium, symptom monitoring and acting as a patient advocate; and (iii) caregiver support-information needs, advice on how to respond to the patient, interventions to improve caregiver outcomes and interventions delivered by caregivers to improve patient outcomes. CONCLUSION High levels of distress are experienced by caregivers of patients with delirium. Distress is heightened because of the potential irreversibility of delirium in palliative care settings and uncertainty around whether the caregiver-patient relationship can be re-established before death. Caregivers can contribute to the management of patient delirium. Additional intervention studies with informational, emotional and behavioural components are required to improve support for caregivers and to help the caregiver support the patient. Reducing caregiver distress should be a goal of any future intervention.© 2016 The Authors. Psycho-Oncology Published by John Wiley & Sons Ltd.
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Affiliation(s)
| | - Jean Lugton
- Marie Curie Hospice Edinburgh, Edinburgh, UK
| | - Catriona Kennedy
- School of Nursing and Midwifery, Robert Gordon University, Aberdeen, UK
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Lloyd RB, Rosenthal LJ. Acute traumatic and depressive symptoms in family members of hospitalized individuals with delirium. Int J Psychiatry Med 2015; 50:191-202. [PMID: 26338657 DOI: 10.1177/0091217415605033] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
OBJECTIVES This study characterized symptoms of acute stress and depression in caregivers present during the hospitalization of a loved one with delirium. METHODS This is an observational, cross-sectional analysis of caregivers of patients hospitalized with delirium. Standardized questionnaires were used in caregiver interviews to assess psychological reactions to traumatic situations and understanding of medical care. RESULTS Of the 40 caregivers recruited, half had significant symptoms of acute stress and 12.5% of caregivers were highly symptomatic across all domains related to trauma. Elevated acute stress was positively correlated with both past or current depression and prior mental health treatment (p < 0.028). The caregivers who ranked witnessing delirium as having a negative impact on their lives were also at elevated risk (p < 0.05). CONCLUSIONS Caregivers witnessing delirium are at elevated risk for experiencing severe acute traumatic and depressive symptoms, and this response might place them at risk for developing traumatic disorders.
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Affiliation(s)
- Robert B Lloyd
- Department of Psychiatry and Behavioral Sciences, Northwestern University, Chicago, IL, USA
| | - Lisa J Rosenthal
- Department of Psychiatry and Behavioral Sciences, Northwestern University, Chicago, IL, USA
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Al-Shahri MZ, Sroor MY, Ghareeb WA, Aboulela EN, Edesa W. Using Neuroleptics to Treat Delirium in Dying Cancer Patients at a Cancer Center in Saudi Arabia. J Pain Palliat Care Pharmacother 2015; 29:365-9. [DOI: 10.3109/15360288.2015.1101638] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
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Day J, Higgins I. Existential Absence: The Lived Experience of Family Members During Their Older Loved One's Delirium. QUALITATIVE HEALTH RESEARCH 2015; 25:1700-1718. [PMID: 25605755 DOI: 10.1177/1049732314568321] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/04/2023]
Abstract
When older people develop delirium, their demeanor changes; they often behave in ways that are out of character and seem to inhabit another world. Despite this, little is known about the experiences of family members who are with their older loved one at this time. This article reports a phenomenological study that involved in-depth interviews with 14 women whose older loved one had delirium. Analysis and interpretation of the data depict the women's experiences as "Changing family portraits: Sudden existential absence during delirium," capturing the way family members lose the taken-for-granted presence of their familiar older loved one and confront a stranger during delirium.
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Affiliation(s)
- Jenny Day
- The University of Newcastle, Callaghan, Australia
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36
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Abstract
Background: An important aim of palliative care is to ensure the highest possible quality of life (QoL) for the family members of patients. Aim: We aimed to determine the QoL of family members of hospitalized patients with end-stage disease, as well as differences in QoL based on socio-demographic characteristics and the patient's functional status, psychological distress, and QoL. Methods: Study participants were 292 family members of terminally ill patients at University Hospital, Ostrava, Czech Republic. To evaluate family members' QoL, we used the Quality of Life in Life-Threatening Illness — Family Carer Version (QOLLTI-F). We used the Hospital Anxiety and Depression Scale (HADS) and the Karnofsky Performance Status (KPS) Scale to assess patients' functional status and psychological distress. Results: A statistically significant difference was found in QoL evaluation based on family members' socio-demographic characteristics in education, employment, and age. A significantly lower QoL score was observed for patients' life partners in six domains. A correlation was found between patients' poorer functional status and family members' lower QoL. We found lower global QoL in family members of patients with depression. Conclusion: Family support is a cornerstone of palliative care. Palliative care professionals should focus on at-risk family members — the life partners of patients, the unemployed, younger people, and those whose ill loved one has a poor functional status.
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Delirium superimposed on dementia: A quantitative and qualitative evaluation of informal caregivers and health care staff experience. J Psychosom Res 2015; 79:272-80. [PMID: 26286892 PMCID: PMC4688906 DOI: 10.1016/j.jpsychores.2015.06.012] [Citation(s) in RCA: 54] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/16/2015] [Revised: 06/16/2015] [Accepted: 06/22/2015] [Indexed: 11/22/2022]
Abstract
OBJECTIVE Delirium superimposed on dementia is common and potentially distressing for patients, caregivers, and health care staff. We quantitatively and qualitatively assessed the experience of informal caregiver and staff (staff nurses, nurse aides, physical therapists) caring for patients with delirium superimposed on dementia. METHODS Caregivers' and staff experience was evaluated three days after delirium superimposed on dementia resolution (T0) with a standardized questionnaire (quantitative interview) and open-ended questions (qualitative interview); caregivers were also evaluated at 1-month follow-up (T1). RESULTS A total of 74 subjects were included; 33 caregivers and 41 health care staff (8 staff nurses, 20 physical therapists, 13 staff nurse aides/health care assistants). Overall, at both T0 and T1, the distress level was moderate among caregivers and mild among health care staff. Caregivers reported, at both T0 and T1, higher distress related to deficits of sustained attention and orientation, hypokinesia/psychomotor retardation, incoherence and delusions. The distress of health care staff related to each specific item of the Delirium-O-Meter was relatively low except for the physical therapists who reported higher level of distress on deficits of sustained/shifting attention and orientation, apathy, hypokinesia/psychomotor retardation, incoherence, delusion, hallucinations, and anxiety/fear. The qualitative evaluation identified important categories of caregivers' and staff feelings related to the delirium experience. CONCLUSIONS This study provides information on the implication of the experience of delirium on caregivers and staff. The distress related to delirium superimposed on dementia underlines the importance of providing continuous training, support and experience for both the caregivers and health care staff to improve the care of patients with delirium superimposed on dementia.
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Vahedian Azimi A, Ebadi A, Ahmadi F, Saadat S. Delirium in Prolonged Hospitalized Patients in the Intensive Care Unit. Trauma Mon 2015; 20:e17874. [PMID: 26290854 PMCID: PMC4538727 DOI: 10.5812/traumamon.17874] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2014] [Revised: 04/13/2014] [Accepted: 04/30/2014] [Indexed: 01/08/2023] Open
Abstract
Background: Prolonged hospitalization in the intensive care unit (ICU) can impose long-term psychological effects on patients. One of the most significant psychological effects from prolonged hospitalization is delirium. Objectives: The aim of this study was to assess the effect of prolonged hospitalization of patients and subsequent delirium in the intensive care unit. Patients and Methods: This conventional content analysis study was conducted in the General Intensive Care Unit of the Shariati Hospital of Tehran University of Medical Sciences, from the beginning of 2013 to 2014. All prolonged hospitalized patients and their families were eligible participants. From the 34 eligible patients and 63 family members, the final numbers of actual patients and family members were 9 and 16, respectively. Several semi-structured interviews were conducted face-to-face with patients and their families in a private room and data were gathered. Results: Two main themes from two different perspectives emerged, 'patients' perspectives' (experiences during ICU hospitalization) and 'family members' perspectives' (supportive-communicational experiences). The main results of this study focused on delirium, Patients' findings were described as pleasant and unpleasant, factual and delusional experiences. Conclusions: Family members are valuable components in the therapeutic process of delirium. Effective use of family members in the delirium caring process can be considered to be one of the key non-medical nursing components in the therapeutic process.
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Affiliation(s)
- Amir Vahedian Azimi
- Trauma Research Center, Nursing Faculty, Baqiyatallah University of Medical Sciences, Tehran, IR Iran
| | - Abbas Ebadi
- Behavioral Sciences Research Center, Nursing Faculty, Baqiyatallah University of Medical Sciences, Tehran, IR Iran
- Corresponding author: Abbas Ebadi, Behavioral Sciences Research Center, Nursing Faculty, Baqiyatallah University of Medical Sciences, P.O. Box: 19575-174, Tehran, IR Iran. Tel: +98-9122149019, Fax: +98-2126127237, E-mail:
| | - Fazlollah Ahmadi
- Department of Nursing, Faculty of Medical Sciences, Tarbiat Modares University, Tehran, IR Iran
| | - Soheil Saadat
- Sina Trauma and Surgery Research Center, Tehran University of Medical Sciences, Tehran, IR Iran
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Hosie A, Lobb E, Agar M, Davidson PM, Phillips J. Identifying the barriers and enablers to palliative care nurses' recognition and assessment of delirium symptoms: a qualitative study. J Pain Symptom Manage 2014; 48:815-30. [PMID: 24726761 DOI: 10.1016/j.jpainsymman.2014.01.008] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/17/2013] [Revised: 01/21/2014] [Accepted: 02/07/2014] [Indexed: 12/27/2022]
Abstract
CONTEXT Delirium is underrecognized by nurses, including those working in palliative care settings where the syndrome occurs frequently. Identifying contextual factors that support and/or hinder palliative care nurses' delirium recognition and assessment capabilities is crucial, to inform development of clinical practice and systems aimed at improving patients' delirium outcomes. OBJECTIVES The aim of the study was to identify nurses' perceptions of the barriers and enablers to recognizing and assessing delirium symptoms in palliative care inpatient settings. METHODS A series of semistructured interviews, guided by critical incident technique, were conducted with nurses working in Australian palliative care inpatient settings. A hypoactive delirium vignette prompted participants' recall of delirium and identification of the perceived factors (barriers and enablers) that impacted on their delirium recognition and assessment capabilities. Thematic content analysis was used to analyze the qualitative data. RESULTS Thirty participants from nine palliative care services provided insights into the barriers and enablers of delirium recognition and assessment in the inpatient setting that were categorized as patient and family, health professional, and system level factors. Analysis revealed five themes, each reflecting both identified barriers and current and/or potential enablers: 1) value in listening to patients and engaging families, 2) assessment is integrated with care delivery, 3) respecting and integrating nurses' observations, 4) addressing nurses' delirium knowledge needs, and 5) integrating delirium recognition and assessment processes. CONCLUSION Supporting the development of palliative care nursing delirium recognition and assessment practice requires attending to a range of barriers and enablers at the patient and family, health professional, and system levels.
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Affiliation(s)
- Annmarie Hosie
- School of Nursing, The University of Notre Dame, Sydney, Darlinghurst, New South Wales, Australia.
| | - Elizabeth Lobb
- School of Nursing, The University of Notre Dame, Sydney, Darlinghurst, New South Wales, Australia; Palliative Care Department, Calvary Health Care Sydney, Kogarah, New South Wales, Australia; Cunningham Centre for Palliative Care, Sacred Heart Hospice, St. Vincent's Health Network, Darlinghurst, New South Wales, Australia; ImPaCCT: Improving Palliative Care through Clinical Trials (New South Wales Palliative Care Clinical Trials Group), South Western Sydney Clinical School, Faculty of Medicine, University of New South Wales, Kensington, New South Wales, Australia
| | - Meera Agar
- ImPaCCT: Improving Palliative Care through Clinical Trials (New South Wales Palliative Care Clinical Trials Group), South Western Sydney Clinical School, Faculty of Medicine, University of New South Wales, Kensington, New South Wales, Australia; Department of Palliative Care, Braeside Hospital, HammondCare, Prairiewood, New South Wales, Australia; Palliative and Supportive Services, Flinders University, Adelaide, South Australia, Australia
| | - Patricia M Davidson
- ImPaCCT: Improving Palliative Care through Clinical Trials (New South Wales Palliative Care Clinical Trials Group), South Western Sydney Clinical School, Faculty of Medicine, University of New South Wales, Kensington, New South Wales, Australia; Faculty of Health, University of Technology, Broadway, New South Wales
| | - Jane Phillips
- School of Nursing, The University of Notre Dame, Sydney, Darlinghurst, New South Wales, Australia; Cunningham Centre for Palliative Care, Sacred Heart Hospice, St. Vincent's Health Network, Darlinghurst, New South Wales, Australia; ImPaCCT: Improving Palliative Care through Clinical Trials (New South Wales Palliative Care Clinical Trials Group), South Western Sydney Clinical School, Faculty of Medicine, University of New South Wales, Kensington, New South Wales, Australia
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Hosie A, Agar M, Lobb E, Davidson PM, Phillips J. Palliative care nurses’ recognition and assessment of patients with delirium symptoms: A qualitative study using critical incident technique. Int J Nurs Stud 2014; 51:1353-65. [DOI: 10.1016/j.ijnurstu.2014.02.005] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2013] [Revised: 02/07/2014] [Accepted: 02/09/2014] [Indexed: 12/20/2022]
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Lawlor PG, Bush SH. Delirium in patients with cancer: assessment, impact, mechanisms and management. Nat Rev Clin Oncol 2014; 12:77-92. [DOI: 10.1038/nrclinonc.2014.147] [Citation(s) in RCA: 76] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
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Bush SH, Kanji S, Pereira JL, Davis DHJ, Currow DC, Meagher D, Rabheru K, Wright D, Bruera E, Hartwick M, Gagnon PR, Gagnon B, Breitbart W, Regnier L, Lawlor PG. Treating an established episode of delirium in palliative care: expert opinion and review of the current evidence base with recommendations for future development. J Pain Symptom Manage 2014; 48:231-248. [PMID: 24480529 PMCID: PMC4081457 DOI: 10.1016/j.jpainsymman.2013.07.018] [Citation(s) in RCA: 51] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/20/2013] [Revised: 07/24/2013] [Accepted: 07/31/2013] [Indexed: 12/20/2022]
Abstract
CONTEXT Delirium is a highly prevalent complication in patients in palliative care settings, especially in the end-of-life context. OBJECTIVES To review the current evidence base for treating episodes of delirium in palliative care settings and propose a framework for future development. METHODS We combined multidisciplinary input from delirium researchers and other purposely selected stakeholders at an international delirium study planning meeting. This was supplemented by a literature search of multiple databases and relevant reference lists to identify studies regarding therapeutic interventions for delirium. RESULTS The context of delirium management in palliative care is highly variable. The standard management of a delirium episode includes the investigation of precipitating and aggravating factors followed by symptomatic treatment with drug therapy. However, the intensity of this management depends on illness trajectory and goals of care in addition to the local availability of both investigative modalities and therapeutic interventions. Pharmacologically, haloperidol remains the practice standard by consensus for symptomatic control. Dosing schedules are derived from expert opinion and various clinical practice guidelines as evidence-based data from palliative care settings are limited. The commonly used pharmacologic interventions for delirium in this population warrant evaluation in clinical trials to examine dosing and titration regimens, different routes of administration, and safety and efficacy compared with placebo. CONCLUSION Delirium treatment is multidimensional and includes the identification of precipitating and aggravating factors. For symptomatic management, haloperidol remains the practice standard. Further high-quality collaborative research investigating the appropriate treatment of this complex syndrome is needed.
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Affiliation(s)
- Shirley H Bush
- Division of Palliative Care (S.H.B., J.L.P., M.H., P.G.L.) and Division of Critical Care (M.H.), Department of Medicine; Department of Psychiatry (K.R.); Department of Family Medicine (L.R.); Department of Epidemiology and Community Medicine (P.G.L.), University of Ottawa; Bruyère Research Institute (S.H.B., J.L.P., P.G.L.), Bruyère Continuing Care; The Ottawa Hospital Research Institute (S.K., P.G.L.); Department of Pharmacy (S.K.) and Department of Radiation Oncology (L.R.); The Ottawa Hospital (K.R., M.H.), Ottawa, Ontario, Canada; Institute of Public Health (D.H.J.D.), University of Cambridge, Cambridge, United Kingdom; Discipline, Palliative and Supportive Services (D.C.C., M.A.), Flinders University, Adelaide, South Australia, Australia; Graduate Entry Medical School (D.M.), University of Limerick, Limerick, Ireland; McGill University (D.W.), Montreal, Quèbec, Canada; Department of Palliative Care and Rehabilitation Medicine (E.B.), The University of Texas M. D. Anderson Cancer Center, Houston, Texas, USA; South West Sydney Clinical School (M.A.), University of New South Wales; Department of Palliative Care (M.A.), Braeside Hospital, HammondCare, Sydney, New South Wales, Australia; Faculty of Pharmacy et Centre de Recherche en Cancèrologie (P.R.G.) and Dèpartement de Mèdecine Familiale et de Mèdecine d'Urgence (B.G.), Universitè Laval; Department of Psychiatry (P.R.G.), CHU de Quèbec; Centre de Recherche du CHU de Quèbec (B.G.), Quèbec City, Quèbec, Canada; and Department of Psychiatry and Behavioral Sciences (W.B.), Memorial Sloan-Kettering Cancer Center, New York, New York, USA
| | - Salmaan Kanji
- Division of Palliative Care (S.H.B., J.L.P., M.H., P.G.L.) and Division of Critical Care (M.H.), Department of Medicine; Department of Psychiatry (K.R.); Department of Family Medicine (L.R.); Department of Epidemiology and Community Medicine (P.G.L.), University of Ottawa; Bruyère Research Institute (S.H.B., J.L.P., P.G.L.), Bruyère Continuing Care; The Ottawa Hospital Research Institute (S.K., P.G.L.); Department of Pharmacy (S.K.) and Department of Radiation Oncology (L.R.); The Ottawa Hospital (K.R., M.H.), Ottawa, Ontario, Canada; Institute of Public Health (D.H.J.D.), University of Cambridge, Cambridge, United Kingdom; Discipline, Palliative and Supportive Services (D.C.C., M.A.), Flinders University, Adelaide, South Australia, Australia; Graduate Entry Medical School (D.M.), University of Limerick, Limerick, Ireland; McGill University (D.W.), Montreal, Quèbec, Canada; Department of Palliative Care and Rehabilitation Medicine (E.B.), The University of Texas M. D. Anderson Cancer Center, Houston, Texas, USA; South West Sydney Clinical School (M.A.), University of New South Wales; Department of Palliative Care (M.A.), Braeside Hospital, HammondCare, Sydney, New South Wales, Australia; Faculty of Pharmacy et Centre de Recherche en Cancèrologie (P.R.G.) and Dèpartement de Mèdecine Familiale et de Mèdecine d'Urgence (B.G.), Universitè Laval; Department of Psychiatry (P.R.G.), CHU de Quèbec; Centre de Recherche du CHU de Quèbec (B.G.), Quèbec City, Quèbec, Canada; and Department of Psychiatry and Behavioral Sciences (W.B.), Memorial Sloan-Kettering Cancer Center, New York, New York, USA
| | - José L Pereira
- Division of Palliative Care (S.H.B., J.L.P., M.H., P.G.L.) and Division of Critical Care (M.H.), Department of Medicine; Department of Psychiatry (K.R.); Department of Family Medicine (L.R.); Department of Epidemiology and Community Medicine (P.G.L.), University of Ottawa; Bruyère Research Institute (S.H.B., J.L.P., P.G.L.), Bruyère Continuing Care; The Ottawa Hospital Research Institute (S.K., P.G.L.); Department of Pharmacy (S.K.) and Department of Radiation Oncology (L.R.); The Ottawa Hospital (K.R., M.H.), Ottawa, Ontario, Canada; Institute of Public Health (D.H.J.D.), University of Cambridge, Cambridge, United Kingdom; Discipline, Palliative and Supportive Services (D.C.C., M.A.), Flinders University, Adelaide, South Australia, Australia; Graduate Entry Medical School (D.M.), University of Limerick, Limerick, Ireland; McGill University (D.W.), Montreal, Quèbec, Canada; Department of Palliative Care and Rehabilitation Medicine (E.B.), The University of Texas M. D. Anderson Cancer Center, Houston, Texas, USA; South West Sydney Clinical School (M.A.), University of New South Wales; Department of Palliative Care (M.A.), Braeside Hospital, HammondCare, Sydney, New South Wales, Australia; Faculty of Pharmacy et Centre de Recherche en Cancèrologie (P.R.G.) and Dèpartement de Mèdecine Familiale et de Mèdecine d'Urgence (B.G.), Universitè Laval; Department of Psychiatry (P.R.G.), CHU de Quèbec; Centre de Recherche du CHU de Quèbec (B.G.), Quèbec City, Quèbec, Canada; and Department of Psychiatry and Behavioral Sciences (W.B.), Memorial Sloan-Kettering Cancer Center, New York, New York, USA
| | - Daniel H J Davis
- Division of Palliative Care (S.H.B., J.L.P., M.H., P.G.L.) and Division of Critical Care (M.H.), Department of Medicine; Department of Psychiatry (K.R.); Department of Family Medicine (L.R.); Department of Epidemiology and Community Medicine (P.G.L.), University of Ottawa; Bruyère Research Institute (S.H.B., J.L.P., P.G.L.), Bruyère Continuing Care; The Ottawa Hospital Research Institute (S.K., P.G.L.); Department of Pharmacy (S.K.) and Department of Radiation Oncology (L.R.); The Ottawa Hospital (K.R., M.H.), Ottawa, Ontario, Canada; Institute of Public Health (D.H.J.D.), University of Cambridge, Cambridge, United Kingdom; Discipline, Palliative and Supportive Services (D.C.C., M.A.), Flinders University, Adelaide, South Australia, Australia; Graduate Entry Medical School (D.M.), University of Limerick, Limerick, Ireland; McGill University (D.W.), Montreal, Quèbec, Canada; Department of Palliative Care and Rehabilitation Medicine (E.B.), The University of Texas M. D. Anderson Cancer Center, Houston, Texas, USA; South West Sydney Clinical School (M.A.), University of New South Wales; Department of Palliative Care (M.A.), Braeside Hospital, HammondCare, Sydney, New South Wales, Australia; Faculty of Pharmacy et Centre de Recherche en Cancèrologie (P.R.G.) and Dèpartement de Mèdecine Familiale et de Mèdecine d'Urgence (B.G.), Universitè Laval; Department of Psychiatry (P.R.G.), CHU de Quèbec; Centre de Recherche du CHU de Quèbec (B.G.), Quèbec City, Quèbec, Canada; and Department of Psychiatry and Behavioral Sciences (W.B.), Memorial Sloan-Kettering Cancer Center, New York, New York, USA
| | - David C Currow
- Division of Palliative Care (S.H.B., J.L.P., M.H., P.G.L.) and Division of Critical Care (M.H.), Department of Medicine; Department of Psychiatry (K.R.); Department of Family Medicine (L.R.); Department of Epidemiology and Community Medicine (P.G.L.), University of Ottawa; Bruyère Research Institute (S.H.B., J.L.P., P.G.L.), Bruyère Continuing Care; The Ottawa Hospital Research Institute (S.K., P.G.L.); Department of Pharmacy (S.K.) and Department of Radiation Oncology (L.R.); The Ottawa Hospital (K.R., M.H.), Ottawa, Ontario, Canada; Institute of Public Health (D.H.J.D.), University of Cambridge, Cambridge, United Kingdom; Discipline, Palliative and Supportive Services (D.C.C., M.A.), Flinders University, Adelaide, South Australia, Australia; Graduate Entry Medical School (D.M.), University of Limerick, Limerick, Ireland; McGill University (D.W.), Montreal, Quèbec, Canada; Department of Palliative Care and Rehabilitation Medicine (E.B.), The University of Texas M. D. Anderson Cancer Center, Houston, Texas, USA; South West Sydney Clinical School (M.A.), University of New South Wales; Department of Palliative Care (M.A.), Braeside Hospital, HammondCare, Sydney, New South Wales, Australia; Faculty of Pharmacy et Centre de Recherche en Cancèrologie (P.R.G.) and Dèpartement de Mèdecine Familiale et de Mèdecine d'Urgence (B.G.), Universitè Laval; Department of Psychiatry (P.R.G.), CHU de Quèbec; Centre de Recherche du CHU de Quèbec (B.G.), Quèbec City, Quèbec, Canada; and Department of Psychiatry and Behavioral Sciences (W.B.), Memorial Sloan-Kettering Cancer Center, New York, New York, USA
| | - David Meagher
- Division of Palliative Care (S.H.B., J.L.P., M.H., P.G.L.) and Division of Critical Care (M.H.), Department of Medicine; Department of Psychiatry (K.R.); Department of Family Medicine (L.R.); Department of Epidemiology and Community Medicine (P.G.L.), University of Ottawa; Bruyère Research Institute (S.H.B., J.L.P., P.G.L.), Bruyère Continuing Care; The Ottawa Hospital Research Institute (S.K., P.G.L.); Department of Pharmacy (S.K.) and Department of Radiation Oncology (L.R.); The Ottawa Hospital (K.R., M.H.), Ottawa, Ontario, Canada; Institute of Public Health (D.H.J.D.), University of Cambridge, Cambridge, United Kingdom; Discipline, Palliative and Supportive Services (D.C.C., M.A.), Flinders University, Adelaide, South Australia, Australia; Graduate Entry Medical School (D.M.), University of Limerick, Limerick, Ireland; McGill University (D.W.), Montreal, Quèbec, Canada; Department of Palliative Care and Rehabilitation Medicine (E.B.), The University of Texas M. D. Anderson Cancer Center, Houston, Texas, USA; South West Sydney Clinical School (M.A.), University of New South Wales; Department of Palliative Care (M.A.), Braeside Hospital, HammondCare, Sydney, New South Wales, Australia; Faculty of Pharmacy et Centre de Recherche en Cancèrologie (P.R.G.) and Dèpartement de Mèdecine Familiale et de Mèdecine d'Urgence (B.G.), Universitè Laval; Department of Psychiatry (P.R.G.), CHU de Quèbec; Centre de Recherche du CHU de Quèbec (B.G.), Quèbec City, Quèbec, Canada; and Department of Psychiatry and Behavioral Sciences (W.B.), Memorial Sloan-Kettering Cancer Center, New York, New York, USA
| | - Kiran Rabheru
- Division of Palliative Care (S.H.B., J.L.P., M.H., P.G.L.) and Division of Critical Care (M.H.), Department of Medicine; Department of Psychiatry (K.R.); Department of Family Medicine (L.R.); Department of Epidemiology and Community Medicine (P.G.L.), University of Ottawa; Bruyère Research Institute (S.H.B., J.L.P., P.G.L.), Bruyère Continuing Care; The Ottawa Hospital Research Institute (S.K., P.G.L.); Department of Pharmacy (S.K.) and Department of Radiation Oncology (L.R.); The Ottawa Hospital (K.R., M.H.), Ottawa, Ontario, Canada; Institute of Public Health (D.H.J.D.), University of Cambridge, Cambridge, United Kingdom; Discipline, Palliative and Supportive Services (D.C.C., M.A.), Flinders University, Adelaide, South Australia, Australia; Graduate Entry Medical School (D.M.), University of Limerick, Limerick, Ireland; McGill University (D.W.), Montreal, Quèbec, Canada; Department of Palliative Care and Rehabilitation Medicine (E.B.), The University of Texas M. D. Anderson Cancer Center, Houston, Texas, USA; South West Sydney Clinical School (M.A.), University of New South Wales; Department of Palliative Care (M.A.), Braeside Hospital, HammondCare, Sydney, New South Wales, Australia; Faculty of Pharmacy et Centre de Recherche en Cancèrologie (P.R.G.) and Dèpartement de Mèdecine Familiale et de Mèdecine d'Urgence (B.G.), Universitè Laval; Department of Psychiatry (P.R.G.), CHU de Quèbec; Centre de Recherche du CHU de Quèbec (B.G.), Quèbec City, Quèbec, Canada; and Department of Psychiatry and Behavioral Sciences (W.B.), Memorial Sloan-Kettering Cancer Center, New York, New York, USA
| | - David Wright
- Division of Palliative Care (S.H.B., J.L.P., M.H., P.G.L.) and Division of Critical Care (M.H.), Department of Medicine; Department of Psychiatry (K.R.); Department of Family Medicine (L.R.); Department of Epidemiology and Community Medicine (P.G.L.), University of Ottawa; Bruyère Research Institute (S.H.B., J.L.P., P.G.L.), Bruyère Continuing Care; The Ottawa Hospital Research Institute (S.K., P.G.L.); Department of Pharmacy (S.K.) and Department of Radiation Oncology (L.R.); The Ottawa Hospital (K.R., M.H.), Ottawa, Ontario, Canada; Institute of Public Health (D.H.J.D.), University of Cambridge, Cambridge, United Kingdom; Discipline, Palliative and Supportive Services (D.C.C., M.A.), Flinders University, Adelaide, South Australia, Australia; Graduate Entry Medical School (D.M.), University of Limerick, Limerick, Ireland; McGill University (D.W.), Montreal, Quèbec, Canada; Department of Palliative Care and Rehabilitation Medicine (E.B.), The University of Texas M. D. Anderson Cancer Center, Houston, Texas, USA; South West Sydney Clinical School (M.A.), University of New South Wales; Department of Palliative Care (M.A.), Braeside Hospital, HammondCare, Sydney, New South Wales, Australia; Faculty of Pharmacy et Centre de Recherche en Cancèrologie (P.R.G.) and Dèpartement de Mèdecine Familiale et de Mèdecine d'Urgence (B.G.), Universitè Laval; Department of Psychiatry (P.R.G.), CHU de Quèbec; Centre de Recherche du CHU de Quèbec (B.G.), Quèbec City, Quèbec, Canada; and Department of Psychiatry and Behavioral Sciences (W.B.), Memorial Sloan-Kettering Cancer Center, New York, New York, USA
| | - Eduardo Bruera
- Division of Palliative Care (S.H.B., J.L.P., M.H., P.G.L.) and Division of Critical Care (M.H.), Department of Medicine; Department of Psychiatry (K.R.); Department of Family Medicine (L.R.); Department of Epidemiology and Community Medicine (P.G.L.), University of Ottawa; Bruyère Research Institute (S.H.B., J.L.P., P.G.L.), Bruyère Continuing Care; The Ottawa Hospital Research Institute (S.K., P.G.L.); Department of Pharmacy (S.K.) and Department of Radiation Oncology (L.R.); The Ottawa Hospital (K.R., M.H.), Ottawa, Ontario, Canada; Institute of Public Health (D.H.J.D.), University of Cambridge, Cambridge, United Kingdom; Discipline, Palliative and Supportive Services (D.C.C., M.A.), Flinders University, Adelaide, South Australia, Australia; Graduate Entry Medical School (D.M.), University of Limerick, Limerick, Ireland; McGill University (D.W.), Montreal, Quèbec, Canada; Department of Palliative Care and Rehabilitation Medicine (E.B.), The University of Texas M. D. Anderson Cancer Center, Houston, Texas, USA; South West Sydney Clinical School (M.A.), University of New South Wales; Department of Palliative Care (M.A.), Braeside Hospital, HammondCare, Sydney, New South Wales, Australia; Faculty of Pharmacy et Centre de Recherche en Cancèrologie (P.R.G.) and Dèpartement de Mèdecine Familiale et de Mèdecine d'Urgence (B.G.), Universitè Laval; Department of Psychiatry (P.R.G.), CHU de Quèbec; Centre de Recherche du CHU de Quèbec (B.G.), Quèbec City, Quèbec, Canada; and Department of Psychiatry and Behavioral Sciences (W.B.), Memorial Sloan-Kettering Cancer Center, New York, New York, USA
| | - Michael Hartwick
- Division of Palliative Care (S.H.B., J.L.P., M.H., P.G.L.) and Division of Critical Care (M.H.), Department of Medicine; Department of Psychiatry (K.R.); Department of Family Medicine (L.R.); Department of Epidemiology and Community Medicine (P.G.L.), University of Ottawa; Bruyère Research Institute (S.H.B., J.L.P., P.G.L.), Bruyère Continuing Care; The Ottawa Hospital Research Institute (S.K., P.G.L.); Department of Pharmacy (S.K.) and Department of Radiation Oncology (L.R.); The Ottawa Hospital (K.R., M.H.), Ottawa, Ontario, Canada; Institute of Public Health (D.H.J.D.), University of Cambridge, Cambridge, United Kingdom; Discipline, Palliative and Supportive Services (D.C.C., M.A.), Flinders University, Adelaide, South Australia, Australia; Graduate Entry Medical School (D.M.), University of Limerick, Limerick, Ireland; McGill University (D.W.), Montreal, Quèbec, Canada; Department of Palliative Care and Rehabilitation Medicine (E.B.), The University of Texas M. D. Anderson Cancer Center, Houston, Texas, USA; South West Sydney Clinical School (M.A.), University of New South Wales; Department of Palliative Care (M.A.), Braeside Hospital, HammondCare, Sydney, New South Wales, Australia; Faculty of Pharmacy et Centre de Recherche en Cancèrologie (P.R.G.) and Dèpartement de Mèdecine Familiale et de Mèdecine d'Urgence (B.G.), Universitè Laval; Department of Psychiatry (P.R.G.), CHU de Quèbec; Centre de Recherche du CHU de Quèbec (B.G.), Quèbec City, Quèbec, Canada; and Department of Psychiatry and Behavioral Sciences (W.B.), Memorial Sloan-Kettering Cancer Center, New York, New York, USA
| | - Pierre R Gagnon
- Division of Palliative Care (S.H.B., J.L.P., M.H., P.G.L.) and Division of Critical Care (M.H.), Department of Medicine; Department of Psychiatry (K.R.); Department of Family Medicine (L.R.); Department of Epidemiology and Community Medicine (P.G.L.), University of Ottawa; Bruyère Research Institute (S.H.B., J.L.P., P.G.L.), Bruyère Continuing Care; The Ottawa Hospital Research Institute (S.K., P.G.L.); Department of Pharmacy (S.K.) and Department of Radiation Oncology (L.R.); The Ottawa Hospital (K.R., M.H.), Ottawa, Ontario, Canada; Institute of Public Health (D.H.J.D.), University of Cambridge, Cambridge, United Kingdom; Discipline, Palliative and Supportive Services (D.C.C., M.A.), Flinders University, Adelaide, South Australia, Australia; Graduate Entry Medical School (D.M.), University of Limerick, Limerick, Ireland; McGill University (D.W.), Montreal, Quèbec, Canada; Department of Palliative Care and Rehabilitation Medicine (E.B.), The University of Texas M. D. Anderson Cancer Center, Houston, Texas, USA; South West Sydney Clinical School (M.A.), University of New South Wales; Department of Palliative Care (M.A.), Braeside Hospital, HammondCare, Sydney, New South Wales, Australia; Faculty of Pharmacy et Centre de Recherche en Cancèrologie (P.R.G.) and Dèpartement de Mèdecine Familiale et de Mèdecine d'Urgence (B.G.), Universitè Laval; Department of Psychiatry (P.R.G.), CHU de Quèbec; Centre de Recherche du CHU de Quèbec (B.G.), Quèbec City, Quèbec, Canada; and Department of Psychiatry and Behavioral Sciences (W.B.), Memorial Sloan-Kettering Cancer Center, New York, New York, USA
| | - Bruno Gagnon
- Division of Palliative Care (S.H.B., J.L.P., M.H., P.G.L.) and Division of Critical Care (M.H.), Department of Medicine; Department of Psychiatry (K.R.); Department of Family Medicine (L.R.); Department of Epidemiology and Community Medicine (P.G.L.), University of Ottawa; Bruyère Research Institute (S.H.B., J.L.P., P.G.L.), Bruyère Continuing Care; The Ottawa Hospital Research Institute (S.K., P.G.L.); Department of Pharmacy (S.K.) and Department of Radiation Oncology (L.R.); The Ottawa Hospital (K.R., M.H.), Ottawa, Ontario, Canada; Institute of Public Health (D.H.J.D.), University of Cambridge, Cambridge, United Kingdom; Discipline, Palliative and Supportive Services (D.C.C., M.A.), Flinders University, Adelaide, South Australia, Australia; Graduate Entry Medical School (D.M.), University of Limerick, Limerick, Ireland; McGill University (D.W.), Montreal, Quèbec, Canada; Department of Palliative Care and Rehabilitation Medicine (E.B.), The University of Texas M. D. Anderson Cancer Center, Houston, Texas, USA; South West Sydney Clinical School (M.A.), University of New South Wales; Department of Palliative Care (M.A.), Braeside Hospital, HammondCare, Sydney, New South Wales, Australia; Faculty of Pharmacy et Centre de Recherche en Cancèrologie (P.R.G.) and Dèpartement de Mèdecine Familiale et de Mèdecine d'Urgence (B.G.), Universitè Laval; Department of Psychiatry (P.R.G.), CHU de Quèbec; Centre de Recherche du CHU de Quèbec (B.G.), Quèbec City, Quèbec, Canada; and Department of Psychiatry and Behavioral Sciences (W.B.), Memorial Sloan-Kettering Cancer Center, New York, New York, USA
| | - William Breitbart
- Division of Palliative Care (S.H.B., J.L.P., M.H., P.G.L.) and Division of Critical Care (M.H.), Department of Medicine; Department of Psychiatry (K.R.); Department of Family Medicine (L.R.); Department of Epidemiology and Community Medicine (P.G.L.), University of Ottawa; Bruyère Research Institute (S.H.B., J.L.P., P.G.L.), Bruyère Continuing Care; The Ottawa Hospital Research Institute (S.K., P.G.L.); Department of Pharmacy (S.K.) and Department of Radiation Oncology (L.R.); The Ottawa Hospital (K.R., M.H.), Ottawa, Ontario, Canada; Institute of Public Health (D.H.J.D.), University of Cambridge, Cambridge, United Kingdom; Discipline, Palliative and Supportive Services (D.C.C., M.A.), Flinders University, Adelaide, South Australia, Australia; Graduate Entry Medical School (D.M.), University of Limerick, Limerick, Ireland; McGill University (D.W.), Montreal, Quèbec, Canada; Department of Palliative Care and Rehabilitation Medicine (E.B.), The University of Texas M. D. Anderson Cancer Center, Houston, Texas, USA; South West Sydney Clinical School (M.A.), University of New South Wales; Department of Palliative Care (M.A.), Braeside Hospital, HammondCare, Sydney, New South Wales, Australia; Faculty of Pharmacy et Centre de Recherche en Cancèrologie (P.R.G.) and Dèpartement de Mèdecine Familiale et de Mèdecine d'Urgence (B.G.), Universitè Laval; Department of Psychiatry (P.R.G.), CHU de Quèbec; Centre de Recherche du CHU de Quèbec (B.G.), Quèbec City, Quèbec, Canada; and Department of Psychiatry and Behavioral Sciences (W.B.), Memorial Sloan-Kettering Cancer Center, New York, New York, USA
| | - Laura Regnier
- Division of Palliative Care (S.H.B., J.L.P., M.H., P.G.L.) and Division of Critical Care (M.H.), Department of Medicine; Department of Psychiatry (K.R.); Department of Family Medicine (L.R.); Department of Epidemiology and Community Medicine (P.G.L.), University of Ottawa; Bruyère Research Institute (S.H.B., J.L.P., P.G.L.), Bruyère Continuing Care; The Ottawa Hospital Research Institute (S.K., P.G.L.); Department of Pharmacy (S.K.) and Department of Radiation Oncology (L.R.); The Ottawa Hospital (K.R., M.H.), Ottawa, Ontario, Canada; Institute of Public Health (D.H.J.D.), University of Cambridge, Cambridge, United Kingdom; Discipline, Palliative and Supportive Services (D.C.C., M.A.), Flinders University, Adelaide, South Australia, Australia; Graduate Entry Medical School (D.M.), University of Limerick, Limerick, Ireland; McGill University (D.W.), Montreal, Quèbec, Canada; Department of Palliative Care and Rehabilitation Medicine (E.B.), The University of Texas M. D. Anderson Cancer Center, Houston, Texas, USA; South West Sydney Clinical School (M.A.), University of New South Wales; Department of Palliative Care (M.A.), Braeside Hospital, HammondCare, Sydney, New South Wales, Australia; Faculty of Pharmacy et Centre de Recherche en Cancèrologie (P.R.G.) and Dèpartement de Mèdecine Familiale et de Mèdecine d'Urgence (B.G.), Universitè Laval; Department of Psychiatry (P.R.G.), CHU de Quèbec; Centre de Recherche du CHU de Quèbec (B.G.), Quèbec City, Quèbec, Canada; and Department of Psychiatry and Behavioral Sciences (W.B.), Memorial Sloan-Kettering Cancer Center, New York, New York, USA
| | - Peter G Lawlor
- Division of Palliative Care (S.H.B., J.L.P., M.H., P.G.L.) and Division of Critical Care (M.H.), Department of Medicine; Department of Psychiatry (K.R.); Department of Family Medicine (L.R.); Department of Epidemiology and Community Medicine (P.G.L.), University of Ottawa; Bruyère Research Institute (S.H.B., J.L.P., P.G.L.), Bruyère Continuing Care; The Ottawa Hospital Research Institute (S.K., P.G.L.); Department of Pharmacy (S.K.) and Department of Radiation Oncology (L.R.); The Ottawa Hospital (K.R., M.H.), Ottawa, Ontario, Canada; Institute of Public Health (D.H.J.D.), University of Cambridge, Cambridge, United Kingdom; Discipline, Palliative and Supportive Services (D.C.C., M.A.), Flinders University, Adelaide, South Australia, Australia; Graduate Entry Medical School (D.M.), University of Limerick, Limerick, Ireland; McGill University (D.W.), Montreal, Quèbec, Canada; Department of Palliative Care and Rehabilitation Medicine (E.B.), The University of Texas M. D. Anderson Cancer Center, Houston, Texas, USA; South West Sydney Clinical School (M.A.), University of New South Wales; Department of Palliative Care (M.A.), Braeside Hospital, HammondCare, Sydney, New South Wales, Australia; Faculty of Pharmacy et Centre de Recherche en Cancèrologie (P.R.G.) and Dèpartement de Mèdecine Familiale et de Mèdecine d'Urgence (B.G.), Universitè Laval; Department of Psychiatry (P.R.G.), CHU de Quèbec; Centre de Recherche du CHU de Quèbec (B.G.), Quèbec City, Quèbec, Canada; and Department of Psychiatry and Behavioral Sciences (W.B.), Memorial Sloan-Kettering Cancer Center, New York, New York, USA
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Wright DK, Brajtman S, Macdonald ME. A relational ethical approach to end-of-life delirium. J Pain Symptom Manage 2014; 48:191-8. [PMID: 24417807 DOI: 10.1016/j.jpainsymman.2013.08.015] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/08/2013] [Revised: 08/17/2013] [Accepted: 08/28/2013] [Indexed: 11/29/2022]
Abstract
Delirium is a condition of acute onset and fluctuating course in which a person's level of consciousness and cognition become disturbed. Delirium is a common and distressing phenomenon in end-of-life care, yet it is underrecognized and undertreated. In this article, we review qualitative descriptions of the delirium experience in end-of-life care, found through a systematic search of academic databases, to generate insight into the intersubjective nature of the delirium experience. Our analysis of retrieved studies advances an understanding of the relational ethical dimensions of this phenomenon, that is, how delirium is lived by patients, families, and health care providers and how it affects the relationships and values at stake. We propose three themes that explain the distressing nature of delirium in palliative care: 1) experiences of relational tension; 2) challenges in recognizing the delirious person; and 3) struggles to interpret the meaning of delirious behaviors. By approaching end-of-life delirium from a perspective of relational ethics, attention is focused on the implications for the therapeutic relationship with patients and families when delirium becomes part of the dying trajectory.
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Affiliation(s)
- David Kenneth Wright
- Department of Biomedical Ethics, McGill University, Montreal, Quebec, Canada; Department of Palliative Care, Jewish General Hospital, Montreal, Quebec, Canada.
| | - Susan Brajtman
- School of Nursing, University of Ottawa, Ottawa, Ontario, Canada; Bruyère Research Institute, Ottawa, Ontario, Canada
| | - Mary Ellen Macdonald
- Faculty of Dentistry, McGill University, Montreal, Quebec, Canada; Pediatric Palliative Care Research, Montreal Children's Hospital of the McGill University Health Centre, Montreal, Quebec, Canada
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Bush SH, Leonard MM, Agar M, Spiller JA, Hosie A, Wright DK, Meagher DJ, Currow DC, Bruera E, Lawlor PG. End-of-life delirium: issues regarding recognition, optimal management, and the role of sedation in the dying phase. J Pain Symptom Manage 2014; 48:215-30. [PMID: 24879997 DOI: 10.1016/j.jpainsymman.2014.05.009] [Citation(s) in RCA: 50] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/03/2014] [Revised: 05/17/2014] [Accepted: 05/21/2014] [Indexed: 01/21/2023]
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 is needed in this patient population.
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Affiliation(s)
- Shirley H Bush
- Division of Palliative Care, Department of Medicine, University of Ottawa, Ottawa, Ontario, Canada; Bruyère Research Institute, Bruyère Continuing Care, Ottawa, Ontario, Canada.
| | - Maeve M Leonard
- Graduate Entry Medical School, University of Limerick, Limerick, Ireland
| | - Meera Agar
- Discipline, Palliative & Supportive Services, Flinders University, Adelaide, South Australia, Australia; South West Sydney Clinical School, University of New South Wales, Sydney, New South Wales, Australia; Department of Palliative Care, Braeside Hospital, HammondCare, Sydney, New South Wales, Australia
| | - Juliet A Spiller
- Palliative Medicine, Marie Curie Hospice, Edinburgh, United Kingdom
| | - Annmarie Hosie
- Faculty of Nursing, University of Notre Dame, Sydney, New South Wales, Australia
| | | | - David J Meagher
- Graduate Entry Medical School, University of Limerick, Limerick, Ireland
| | - David C Currow
- Discipline, Palliative & Supportive Services, Flinders University, Adelaide, South Australia, Australia
| | - Eduardo Bruera
- The University of Texas M. D. Anderson Cancer Center, Houston, Texas, USA
| | - Peter G Lawlor
- Bruyère Research Institute, Bruyère Continuing Care, Ottawa, Ontario, Canada; Division of Palliative Care, Department of Medicine, Epidemiology and Community Medicine, University of Ottawa, Ottawa, Ontario, Canada; The Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
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Leonard MM, Agar M, Spiller JA, Davis B, Mohamad MM, Meagher DJ, Lawlor PG. Delirium diagnostic and classification challenges in palliative care: subsyndromal delirium, comorbid delirium-dementia, and psychomotor subtypes. J Pain Symptom Manage 2014; 48:199-214. [PMID: 24879995 DOI: 10.1016/j.jpainsymman.2014.03.012] [Citation(s) in RCA: 37] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/20/2014] [Revised: 03/17/2014] [Accepted: 04/02/2014] [Indexed: 12/19/2022]
Abstract
CONTEXT Delirium often presents difficult diagnostic and classification challenges in palliative care settings. OBJECTIVES To review three major areas that create diagnostic and classification challenges in relation to delirium in palliative care: subsyndromal delirium (SSD), delirium in the context of comorbid dementia, and classification of psychomotor subtypes, and to identify knowledge gaps and research priorities in relation to these three areas of focus. METHODS We combined multidisciplinary input from delirium researchers and knowledge users at an international delirium study planning meeting and relevant PubMed literature searches as the knowledge synthesis strategy in this review. RESULTS We identified six (SSD), 33 (dementia), and 44 (psychomotor subtypes) articles of relevance in relation to the focus of our review. Recent literature data highlight the frequency and impact of SSD, the relevance of comorbid dementia, and the propensity for a hypoactive presentation of delirium in the palliative population. The differential diagnoses to consider are wide and include pain, fatigue, mood disturbance, psychoactive medication effects, and other causes for altered consciousness. CONCLUSION Challenges in the diagnosis and classification of delirium in people with advanced disease are compounded by the generalized disturbance of central nervous system function that occurs in the seriously ill, often with comorbid illness, including dementia. Further research is needed to delineate the pathophysiological and clinical associations of these presentations and thus inform therapeutic strategies. The expanding aged population and growing focus on dementia care in palliative care highlight the need to conduct this research.
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Affiliation(s)
- Maeve M Leonard
- Graduate Entry Medical School, University of Limerick, Limerick, Ireland
| | - Meera Agar
- Discipline, Palliative & Supportive Services, Flinders University, Adelaide, South Australia, Australia; South West Sydney Clinical School, University of New South Wales, Sydney, New South Wales, Australia; Department of Palliative Care, Braeside Hospital, HammondCare, Sydney, New South Wales, Australia
| | - Juliet A Spiller
- Palliative Medicine, Marie Curie Hospice, Edinburgh and West Lothian Palliative Care Service, Edinburgh, United Kingdom
| | - Brid Davis
- Milford Care Centre, University of Limerick, Limerick, Ireland
| | - Mas M Mohamad
- Milford Care Centre, University of Limerick, Limerick, Ireland
| | - David J Meagher
- Graduate Entry Medical School, University of Limerick, Limerick, Ireland
| | - Peter G Lawlor
- Bruyère Research Institute, Bruyère Continuing Care, Ottawa, Ontario, Canada; Division of Palliative Care, Department of Medicine, Epidemiology and Community Medicine, University of Ottawa, Ottawa, Ontario, Canada; The Ottawa Hospital Research Institute, Ottawa, Ontario, Canada.
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Mailhot T, Cossette S, Bourbonnais A, Côté J, Denault A, Côté MC, Lamarche Y, Guertin MC. Evaluation of a nurse mentoring intervention to family caregivers in the management of delirium after cardiac surgery (MENTOR_D): a study protocol for a randomized controlled pilot trial. Trials 2014; 15:306. [PMID: 25073881 PMCID: PMC4133622 DOI: 10.1186/1745-6215-15-306] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2014] [Accepted: 07/08/2014] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Despite the use of evidence-based preventive measures, delirium affects about 40% of patients following cardiac surgery with the potential for serious clinical complications and anxiety for caregivers. There is some evidence that family involvement as a core component of delirium management may be beneficial since familiarity helps patients stay in contact with reality, however, this merits further investigation. There is also currently a gap in the scientific literature regarding objective indicators that could enhance early detection and monitoring of delirium. Therefore, this randomized pilot trial examines the acceptability, feasibility, and preliminary efficacy of an experimental nursing intervention to help family caregivers manage post-cardiac surgery delirium in their relatives. It also explores the validity of a new and innovative measure that has potential as an indicator for delirium. METHODS/DESIGN In this two-group randomized pilot study (n = 30), the control group will receive usual care and the intervention group will receive the experimental intervention aimed at reducing delirium severity. The intervention nurse's objective will be to foster the family caregiver's self-efficacy in behaving in a supportive manner during delirium episodes. Data will be collected from standard delirium assessment scales and a novel measure of delirium, i.e., cerebral oximetry obtained using near infrared spectroscopy, as well as medical records and participants' responses to questionnaires. DISCUSSION New strategies for early detection, monitoring, and management of delirium are needed in order to improve outcomes for both patients and families. The present article exposes feasibility issues based on the first few months of the empirical phase of the study that may be useful to the scientific community interested in improving the care of patients with delirium. Another potentially important contribution is in the exploration of cerebral oximetry, a promising measure as an objective indicator for early detection and continuous monitoring of delirium. The proposed pilot study will build towards a larger trial with the potential to improve knowledge about delirium management and monitoring. TRIAL REGISTRATION This pilot study was registered at Controlled Trials on March 27th 2013 and was assigned #ISRCTN95736036.
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Affiliation(s)
- Tanya Mailhot
- Faculty of Nursing, University of Montreal, C,P, 6128 succ, Centre-ville, Montreal, Quebec H3C 3J7, Canada.
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Family stories of end-of-life cancer care when unable to fulfill a loved one's wish to die at home. Palliat Support Care 2014; 13:473-83. [PMID: 24621995 DOI: 10.1017/s1478951514000017] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Control over place of death is deemed important, not only in providing a "good death," but also in offering person-centered palliative care. Despite the wish to die at home being endorsed by many, few achieve it. The present study aimed to explore the reasons why this wish is not fulfilled by examining the stories of ten individuals who lost a loved one to cancer. METHOD We adopted a narrative approach, with stories synthesized to create one metastory depicting plot similarities and differences. RESULTS Stories were divided into four chapters: (1) the cancer diagnosis, (2) the terminal stage and advancement of death, (3) death itself, and (4) reflections on the whole experience. Additionally, several reasons for cessation of home care were uncovered, including the need to consider children's welfare, exhaustion, and admission of the loved one by professionals due to a medical emergency. Some participants described adverse effects as a result of being unable to continue to support their loved one's wish to remain at home. SIGNIFICANCE OF RESULTS Reflections upon the accounts are provided with a discussion around potential clinical implications.
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Sizoo EM, Grisold W, Taphoorn MJB. Neurologic aspects of palliative care: the end of life setting. HANDBOOK OF CLINICAL NEUROLOGY 2014; 121:1219-1225. [PMID: 24365413 DOI: 10.1016/b978-0-7020-4088-7.00081-x] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/03/2023]
Abstract
As there are, to date, few curative treatment options for many neurologic diseases, end of life (EOL) care is an important aspect of the treatment of neurologic patients. In the EOL phase, treatment should be aimed at relieving symptoms, maintaining quality of life, and facilitating a peaceful and dignified way of dying. Common signs and symptoms in the EOL phase of neurologic patients are raised intracranial pressure, seizures, confusion, cognitive deficits, and impaired motor function. Supportive treatment of these symptoms (such as analgesic drugs, dexamethasone, antiepileptic and neuroleptic drugs) is of major importance to maintain quality of life as long as possible. Another key aspect of EOL care is EOL decision making, such as withholding or withdrawing life-sustaining treatment, and palliative sedation. The main goal of EOL decision making is the prevention and relief of suffering, even if this might hasten death. Especially in advanced stages of many neurologic diseases, confusion, cognitive deficits, communication deficits, and decreasing levels of consciousness may impair the competence of patients to participate in EOL decision making. Given that patient autonomy is increasingly essential, advance care planning (ACP) at an early stage of the disease should be considered.
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Affiliation(s)
- Eefje M Sizoo
- Department of Neurology, VU University Medical Center, Amsterdam, The Netherlands.
| | - Wolfgang Grisold
- Department of Neurology, Kaiser Franz Josep Hospital, Vienna, Austria
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Partridge JSL, Martin FC, Harari D, Dhesi JK. The delirium experience: what is the effect on patients, relatives and staff and what can be done to modify this? Int J Geriatr Psychiatry 2013; 28:804-12. [PMID: 23112139 DOI: 10.1002/gps.3900] [Citation(s) in RCA: 126] [Impact Index Per Article: 11.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/24/2012] [Accepted: 10/10/2012] [Indexed: 12/26/2022]
Abstract
BACKGROUND Delirium is a common clinical syndrome with significant associated mortality, morbidity and financial cost. Less is understood about the experience of delirium for the patient, their family and staff involved in their care. OBJECTIVE This synthesis draws on qualitative and quantitative literature examining different populations (patients, relatives and staff) in different clinical settings (intensive care units, surgery and hospice care) to provide a clinical summary of the delirium experience from the perspective of patients, relatives and staff. DESIGN A literature search was conducted in Ovid, MEDLINE, Embase, PsychINFO, British Nursing Index and Archive and PubMed between 1980 and 2011 using the terms 'delirium' combined with 'distress', 'recall', 'anxiety', 'depression', 'PTSD', 'experience' and 'patient education'. Articles were restricted to English language only. RESULTS Evidence suggests that some patients recall delirium and that recollections are generally distressing. Distress may be greater in relatives witnessing delirium and is also reported in professional staff. This distress may result in longer-term psychological sequelae. Remedial action, such as explanatory information to patients and their families, may reduce distress and psychological morbidity. CONCLUSIONS A better understanding of the experience and psychological consequences of delirium will inform the development of appropriate methods of providing support and information to those at risk of delirium and their families or carers.
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