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Altered States of Consciousness at the End-of-Life James Hallenbeck, MD Director, Palliative Care Services, VA Palo Alto HCS Assistant Professor of Medicine.

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Presentation on theme: "Altered States of Consciousness at the End-of-Life James Hallenbeck, MD Director, Palliative Care Services, VA Palo Alto HCS Assistant Professor of Medicine."— Presentation transcript:

1 Altered States of Consciousness at the End-of-Life James Hallenbeck, MD Director, Palliative Care Services, VA Palo Alto HCS Assistant Professor of Medicine

2 Psychiatric 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?

3 Common Approach to Problem Medical review - ? Brain metastases Medical review - ? Brain metastases Medication review Medication review On morphine sustained release 150 mg q 12 with 30 mg morphine q2 for breakthrough pain On morphine sustained release 150 mg q 12 with 30 mg morphine q2 for breakthrough pain Decadron 6 mg qd. Decadron 6 mg qd. Metabolic review: at risk for hypercalcemia, hyponatremia Metabolic review: at risk for hypercalcemia, hyponatremia Interview patient – assess orientation and perhaps perform mini-mental status exam. Interview patient – assess orientation and perhaps perform mini-mental status exam.

4 By the end of this talk you should be able to Discuss whether this might be normal dying or not Discuss whether this might be normal dying or not Identify whether this is this a toxic delirium, a terminal delirium or a normal altered state of dying Identify whether this is this a toxic delirium, a terminal delirium or a normal altered state of dying Discuss how these different states might be assessed and managed at the end-of-life Discuss how these different states might be assessed and managed at the end-of-life

5 Delirium – a problem of definitions… Latin – delirare to be deranged. Latin – delirare to be deranged. Definition 1: A state of temporary mental confusion. Definition 1: A state of temporary mental confusion. Definition 2: A state of uncontrolled emotion, esp. excitement. as in Deliriously happy Definition 2: A state of uncontrolled emotion, esp. excitement. as in Deliriously happy Websters II New College Dictionary

6 DSMIV Definition of Delirium Disturbance of consciousness (reduced clarity of awareness of environment) 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 for Change in cognition (memory deficit, disorientation, language disturbance) or the development of a perceptual disturbance not otherwise accounted for Development of the disturbance during a short time period with a tendency to fluctuate. Development 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. Evidence that the disturbance is caused by the direct physiological consequences of a general medical condition.

7 Altered State of Consciousness Definition: A state of consciousness that is other than normal wakefulness Definition: A state of consciousness that is other than normal wakefulness Can be good, neutral or bad qualitatively Can be good, neutral or bad qualitatively Bad altered states can be called delirium Bad altered states can be called delirium

8 Altered States at the End-of-Life Common – prevalence of 25-85% Common – prevalence of 25-85% Exist along spectrums: Exist along spectrums: Normal --------- ---------Abnormal Normal --------- ---------Abnormal Pleasant/ecstatic --------Very Disturbing Pleasant/ecstatic --------Very Disturbing Reversible----------------Irreversible Reversible----------------Irreversible

9 Toxic (standard issue) Delirium Reversible – often has correctable cause Reversible – often has correctable cause Associated with periodic agitated states Associated with periodic agitated states Psychedelic colors, rhythmic patterns (green ants, purple cows) Psychedelic colors, rhythmic patterns (green ants, purple cows) Tends to occur earlier in the dying trajectory Tends to occur earlier in the dying trajectory Suspect if sudden change in functional and health status or with change in medication Suspect if sudden change in functional and health status or with change in medication

10 Terminal Delirium Occurs in patient identified as being very close (days) to death Occurs in patient identified as being very close (days) to death Relatively irreversible Relatively irreversible May mix components of toxic delirium with dream-like stories involving people May mix components of toxic delirium with dream-like stories involving people

11 Overlap in Altered States

12 Prospective Study of Delirium Delirium present on admission 44 (42%) Delirium present on admission 44 (42%) Delirium developed in 44 (42%) of remaining 60 patients Delirium developed in 44 (42%) of remaining 60 patients Delirium proximal to death: 46 (88%) of 52 deaths Delirium proximal to death: 46 (88%) of 52 deaths Key Findings Of 104 Patients admitted to inpatient unit: Lawlor, P. and B. Gagnon (2000). "Occurrence, causes, and outcomes of delirium in patients with advanced cancer: a prospective study." Archives of Internal Medicine 160: 786-794.

13 Reversibility in Delirium Reversibility of delirium 46/94 episodes in 71 patients 49% Reversibility of delirium 46/94 episodes in 71 patients 49% Univariate associates with delirium: Associated with reversibility: Univariate associates with delirium: Associated with reversibility: Opioids HR: 8.85 (2.13-26.74) Opioids HR: 8.85 (2.13-26.74) Dehydration: 2.35 (1.20-4.62) Dehydration: 2.35 (1.20-4.62) Associated with irreversibility: Associated with irreversibility: Hypoxic encephalopathy: 0.32 (.15-.70) Hypoxic encephalopathy: 0.32 (.15-.70) Metabolic factors: 0.44 (0.21-.91 Metabolic factors: 0.44 (0.21-.91

14 Key Questions regarding altered states What is the prognosis and dying trajectory? What is the prognosis and dying trajectory? Is the experience disturbing? (And who is disturbed – pt, family, staff) Is the experience disturbing? (And who is disturbed – pt, family, staff) If so, why? If so, why? What are the goals of care? What are the goals of care?

15 Dying Trajectories

16 Distress in Altered States Who Who Patients Patients Families – may project concerns onto patient Families – may project concerns onto patient Clinicians – worries about decision making, communication, staff time Clinicians – worries about decision making, communication, staff time

17 Goals of Care Assume everybody wants to be comfortable Assume everybody wants to be comfortable Spectrum – comfort only – aggressive life- prolongation Spectrum – comfort only – aggressive life- prolongation Have trade-offs been addressed Have trade-offs been addressed Especially when distress-free alertness is impossible to achieve? Especially when distress-free alertness is impossible to achieve?

18 Distress in Altered States What is distressing? What is distressing? Content Content Lack of clarity – difficulty thinking, communicating Lack of clarity – difficulty thinking, communicating Level of consciousness – compare to desired level of consciousness Level of consciousness – compare to desired level of consciousness Higher Higher Lower Lower

19 Helpful Hints Best screening question: What time is it? Best screening question: What time is it? In assessing orientation to time, separate memory (date, year) from true orientation In assessing orientation to time, separate memory (date, year) from true orientation Weigh benefits and burdens of what you start and stop Weigh benefits and burdens of what you start and stop Example – hydration might improve delirium, but is need to tie-down the patient for an IV worth the price? Example – hydration might improve delirium, but is need to tie-down the patient for an IV worth the price?

20 Regarding opioids Reducing opioid dose by 20-30% if patient has zero to minimal pain, NOT stopping Reducing opioid dose by 20-30% if patient has zero to minimal pain, NOT stopping Opioid rotation, when significant pain present, especially when on morphine Opioid rotation, when significant pain present, especially when on morphine Alternatives: hydromorphone, oxycodone, fentanyl Alternatives: hydromorphone, oxycodone, fentanyl Evaluate for adjunctive therapy that might allow reduction in opioid dosing Evaluate for adjunctive therapy that might allow reduction in opioid dosing Consider: REMEMBER: UNTREATED PAIN AND OPIOID WITHDRAWAL ALSO WORSEN DELIRIUM

21 Medications Key question: To what extent are you trying to reorient, sedate or do both? Key question: To what extent are you trying to reorient, sedate or do both? Re-orient – non-sedating neuroleptics Re-orient – non-sedating neuroleptics Sedate – benzodiazepines, sedating neuroleptics (chlorpromazine) barbiturates Sedate – benzodiazepines, sedating neuroleptics (chlorpromazine) barbiturates Both – chlorpromazine Both – chlorpromazine

22 Visitations Incidence: at least 25% of dying people Incidence: at least 25% of dying people Trans-cultural – not associated with religiosity Trans-cultural – not associated with religiosity Rarely disturbing to patients Rarely disturbing to patients Visitors: Visitors: Deceased relatives and friends Deceased relatives and friends Guardian spirits/angels Guardian spirits/angels Babies and children Babies and children Key Point: Seeing angels is not an indication for Haloperidol!

23 Common themes Travel Travel Crossing-over, barriers Crossing-over, barriers Reuniting Reuniting Unfinished business Unfinished business Flash-backs and fears Flash-backs and fears

24 SUMMARY Altered states are common Altered states are common Not all altered states are bad or abnormal or reversible Not all altered states are bad or abnormal or reversible Need for flexibility in management Need for flexibility in management More research is needed in both understanding and managing such states More research is needed in both understanding and managing such states


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