Presentation on theme: "Altered States of Consciousness at the End-of-Life"— Presentation transcript:
1Altered States of Consciousness at the End-of-Life James Hallenbeck, MDDirector, Palliative Care Services, VA Palo Alto HCSAssistant Professor of Medicine
2Psychiatric Consultation Situation: A psychiatric consultation is called for a patient with metastatic small cell carcinoma of the lung to determine “competency” (sic) regarding decision making and because the patient has been intermittently sleepy and agitated, calling out to unseen people. What approach do you take to such a consult?
3Common Approach to Problem Medical review - ? Brain metastasesMedication reviewOn morphine sustained release 150 mg q 12 with 30 mg morphine q2 for breakthrough painDecadron 6 mg qd.Metabolic review: at risk for hypercalcemia, hyponatremiaInterview patient – assess orientation and perhaps perform mini-mental status exam.
4By the end of this talk you should be able to Discuss whether this might be normal dying or notIdentify whether this is this a toxic delirium, a terminal delirium or a “normal altered state” of dyingDiscuss how these different states might be assessed and managed at the end-of-life
5Delirium – a problem of definitions… Latin – delirare to be deranged.Definition 1: “A state of temporary mental confusion.”Definition 2: “A state of uncontrolled emotion, esp. excitement.” as in “Deliriously happy”Websters II New College Dictionary
6DSMIV Definition of Delirium Disturbance of consciousness (reduced clarity of awareness of environment)Change in cognition (memory deficit, disorientation, language disturbance) or the development of a perceptual disturbance not otherwise accounted forDevelopment of the disturbance during a short time period with a tendency to fluctuate.Evidence that the disturbance is caused by the direct physiological consequences of a general medical condition.
7Altered State of Consciousness Definition: A state of consciousness that is other than normal wakefulnessCan be good, neutral or bad qualitativelyBad altered states can be called delirium
8Altered States at the End-of-Life Common – prevalence of 25-85%Exist along spectrums:Normal AbnormalPleasant/ecstatic Very DisturbingReversible Irreversible
9Toxic (standard issue) Delirium Reversible – often has correctable causeAssociated with periodic agitated statesPsychedelic colors, rhythmic patterns (green ants, purple cows)Tends to occur earlier in the dying trajectorySuspect if sudden change in functional and health status or with change in medication
10Terminal DeliriumOccurs in patient identified as being very close (days) to deathRelatively irreversibleMay mix components of toxic delirium with dream-like stories involving people
12Prospective Study of Delirium Key FindingsOf 104 Patients admitted to inpatient unit:Delirium present on admission 44 (42%)Delirium developed in 44 (42%) of remaining 60 patientsDelirium proximal to death: 46 (88%) of 52 deathsLawlor, P. and B. Gagnon (2000). "Occurrence, causes, and outcomes of delirium in patients with advanced cancer: a prospective study." Archives of Internal Medicine 160:
13Reversibility in Delirium Reversibility of delirium 46/94 episodes in 71 patients 49%Univariate associates with delirium: Associated with reversibility:Opioids HR: 8.85 ( )Dehydration: 2.35 ( )Associated with irreversibility:Hypoxic encephalopathy: ( )Metabolic factors: 0.44 (
14Key Questions regarding altered states What is the prognosis and dying trajectory?Is the experience disturbing? (And who is disturbed – pt, family, staff)If so, why?What are the goals of care?
16Distress in Altered States WhoPatientsFamilies – may project concerns onto patientClinicians – worries about decision making, communication, staff time
17Goals of Care Assume everybody wants to be comfortable Spectrum – comfort only – aggressive life-prolongationHave trade-offs been addressedEspecially when distress-free alertness is impossible to achieve?
18Distress in Altered States What is distressing?ContentLack of clarity – difficulty thinking, communicatingLevel of consciousness – compare to desired level of consciousnessHigherLower
19Helpful Hints Best screening question: “What time is it?” In assessing orientation to time, separate memory (date, year) from true orientationWeigh benefits and burdens of what you start and stopExample – hydration might improve delirium, but is need to tie-down the patient for an IV worth the price?
20Regarding opioidsConsider:Reducing opioid dose by 20-30% if patient has zero to minimal pain, NOT stoppingOpioid rotation, when significant pain present, especially when on morphineAlternatives: hydromorphone, oxycodone, fentanylEvaluate for adjunctive therapy that might allow reduction in opioid dosingREMEMBER: UNTREATED PAIN AND OPIOID WITHDRAWAL ALSO WORSEN DELIRIUM
21MedicationsKey question: To what extent are you trying to reorient, sedate or do both?Re-orient – non-sedating neurolepticsSedate – benzodiazepines, sedating neuroleptics (chlorpromazine) barbituratesBoth – chlorpromazine
22Visitations Incidence: at least 25% of dying people Trans-cultural – not associated with religiosityRarely disturbing to patientsVisitors:Deceased relatives and friendsGuardian spirits/angelsBabies and childrenKey Point: Seeing angels is not an indication for Haloperidol!
23Common themes Travel Crossing-over, barriers Reuniting Unfinished businessFlash-backs and fears
24SUMMARY Altered states are common Not all altered states are bad or abnormal or reversibleNeed for flexibility in managementMore research is needed in both understanding and managing such states