General Management Approach to Delirium
The relatively short period between onset of sedation and death has been consistently reported as 1 to 6 days. It has been noted, however, that palliative care patients who have delirium and appear extremely ill may still have treatable, reversible complications.[46,47,48,49]
Various medications have been utilized for palliative sedation.[50,51] These include benzodiazepines (midazolam), phenothiazines (methotrimeprazine, chlorpromazine), butyrophenones (haloperidol), anaesthetic agents (propofol), and barbiturates. Midazolam is the drug most frequently reported as useful because of its rapid onset and ease of titration. Choice of medication is often determined by clinician preference and/or institutional policy.
Given the common association between delirium and sedation, it is important to have some understanding of the extensive literature on the ethical validity of using sedation management. Numerous articles have addressed the importance of the double-effect argument as applied to the practice of sedation in palliative care. The concept of the double effect distinguishes between the compelling primary intent to relieve suffering and the unavoidable consequence of potentially accelerating death. Legal opinions tend to support the doctrine of double effect as a major ethical foundation for the distinction between palliative care and euthanasia. One study proposed physician intent, proportionality, and autonomy as the ethical principles relevant to palliative sedation therapy. A prospective study of 102 palliative care patients in 21 (out of 56) palliative care units in Japan found that these principles were generally followed when continuous deep palliative sedation therapy was used, supporting the ethical validity of these decisions. The following principles have been recommended as a decision-making guide for sedation for refractory delirium:[38,53,54]
- The designation of a refractory problem should follow repeat assessments by skilled clinicians familiar with palliative care. Appropriate assessment and management should be completed in the context of a relationship with the patient and family. Other palliative care clinicians should be consulted if necessary.
- The need for a sedative management approach should ideally be evaluated during a team conference to avoid individual clinician bias or burnout.
- If sedation is considered appropriate and reasonable, temporary sedation should be considered.
- A multidisciplinary assessment of the family should ensure that their views are adequately assessed and understood.
Some families may need continuous information and professional guidance when palliative sedation is used, and this need increases with the duration of the sedation. Individuals or groups outside the family and health care team may have strong opinions about palliative sedation and may offer unsolicited guidance that conflicts with what the patient desires. Concerns identified in a study conducted in The Netherlands relate to the following:
- Aim of continuous sedation.
- Patient well-being.
- Family well-being.
Current Clinical Trials
Check NCI's list of cancer clinical trials for U.S. supportive and palliative care trials about cognitive/functional effects that are now accepting participants. The list of trials can be further narrowed by location, drug, intervention, and other criteria.