Sadly, many clinicians have been poorly trained in this area and cannot distinguish among toxic delirium, terminal delirium, and normal altered states. Clinicians may not recognize that the patient is, in fact, dying. To approach altered states using the standard algorithm for toxic delirium can have disastrous consequences. Medications are reviewed for those that might cause delirium. Often, such medications are then withheld. In toxic delirium, such an approach often results in clinical improvement. Most dying patients I see are on opioids for pain and really need them. Sudden cessation of opioids results in chemical withdrawal and pain exacerbation that usually worsens the patient's delirium content. A new devil with a pitchfork may then appear.
While good studies are lacking, a number of experts in the field have commented that one of the factors that distinguishes terminal from nonterminal (toxic) delirium is that terminal delirium may not improve with standard therapy, such as medication withdrawal and the administration of neuroleptics.44,45 That is, disorientation continues, although it may be improved in mild cases. Pharmacologic treatment revolves around a central question: is the goal of therapy to reorient the patient or sedate the patient? Standard therapy for delirium focuses almost exclusively on the first goal, reorientation. For refractory distress, reorientation simply does not work in advanced stages of dying. Sedation is frequently the only available pharmacologic option. Breitbart estimates that this is necessary in one-third of cases.45
Mild cases may respond to medications such as haloperidol (or newer neuroleptics such as risperidone and olanzapine) and result in improved orientation. However, severe disorientation associated with distress rarely returns to normal. Haloperidol can be given either as a standing order or as an as-needed medication with upward titration as appropriate. It is important to understand that haloperidol has minimal sedating effects. If patients become less agitated, it is usually because they are better oriented. Haloperidol has been found to be particularly useful for patients with disorientation at night (sundowning), as in dementia. Patients with Parkinson's disease cannot tolerate haloperidol. Risperidone or olanzapine may be used in its stead. Psychiatrists may assist with the dosing of these agents.
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Palliative Care Perspectives
James L. Hallenbeck, M.D.
Copyright © 2003 by Oxford University Press, Inc.
The online version of this book is used with permission of the publisher and author on web sites affiliated with the Inter-Institutional Collaborating Network on End-of-life Care (IICN), sponsored by Growth House, Inc.