Common Symptoms at End of Life and Their Treatment continued...
Nonpharmacologic interventions include repositioning the patient by elevating the head of the bed or turning the patient to either side. Reducing or eliminating additional fluids and feedings alleviates additional fluid accumulation in the body. Family members may request suctioning, but this can be traumatic and cause bleeding or stimulate the gag reflex. If truly indicated, suctioning should not be done beyond the oral cavity.
Delirium is common during the final days of life.[5,66] There are two general presentations of delirium: hyperactive and hypoactive. (Refer to the PDQ summary on Delirium for a complete review.) The hyperactive form of delirium includes agitation, hallucinations, and restlessness. In hypoactive delirium, the patient is withdrawn and quiet; as a result, this form of delirium may be underdiagnosed.[Level of evidence: II] Although the etiology of either form of delirium is poorly understood, metabolic changes (e.g., hypercalcemia, hypoglycemia, opioid metabolites), dehydration, and drug interactions are implicated.[68,69,70][Level of evidence: II] Other potential causes of delirium include cancer within the CNS, a full bladder, fecal impaction, dyspnea, or withdrawal from alcohol or benzodiazepines.
Care of the patient with delirium can include stopping unnecessary medications, reversing metabolic abnormalities (if consistent with the goals of care), treating the symptoms of delirium, providing parenteral hydration, and providing a safe environment. Agents known to cause delirium include corticosteroids, chemotherapeutic agents, biological response modifiers, opioids, antidepressants, benzodiazepines, and anticholinergic agents. In a small, open-label, prospective trial of 20 cancer patients who developed delirium while being treated with morphine, rotation to fentanyl reduced delirium and improved pain control in 18 patients.[Level of evidence: II] To limit the potential for drug interactions, medications that are no longer useful or that are inconsistent with the goals of care should be stopped. For example, cholesterol-lowering agents are rarely beneficial at this time of life, but many patients admitted to hospice remain on these medications.
Onset of effect and nonoral modes of delivery should be considered when an agent is being selected to treat delirium at the end of life. Agents that can relieve delirium relatively quickly include haloperidol, 1 mg to 4 mg orally, intravenously, or subcutaneously. The dose is usually repeated every 6 hours but in severe cases can be administered every hour. Other agents that may be effective include olanzapine, 2.5 mg to 20 mg orally at night (available in an orally disintegrating tablet for patients who cannot swallow).[Level of evidence: II] Although benzodiazepines (such as lorazepam) or atypical antipsychotics typically exacerbate delirium, they may be useful in delirium related to alcohol withdrawal and for hyperactive delirium that is not controlled by antipsychotics and other supportive measures. Chlorpromazine can be used, but intravenous administration can lead to severe hypotension; therefore, it should be used cautiously. In intractable cases of delirium, palliative sedation may be warranted. Safety measures include protecting patients from accidents or self-injury while they are restless or agitated. The use of restraints is controversial; other strategies include having family members or sitters at the bedside to prevent harm. Reorientation strategies are of little use during the final hours of life. Education and support for families witnessing a loved one's delirium are warranted; one survey of family members found high levels of distress caused by observing delirium.[Level of evidence: II]