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
Medication review
On morphine sustained release 150 mg q 12 with 30 mg morphine q2 for breakthrough pain
Decadron 6 mg qd.
Metabolic review: at risk for hypercalcemia, hyponatremia
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
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

5. Delirium – 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

6. DSMIV 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 for
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.

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

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

9. Toxic (standard issue) Delirium
Reversible – often has correctable cause
Associated with periodic agitated states
Psychedelic colors, rhythmic patterns (green ants, purple cows)
Tends to occur earlier in the dying trajectory
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
Relatively irreversible
May mix components of toxic delirium with dream-like stories involving people

11. Overlap in Altered States

12. Prospective Study of Delirium
Key Findings
Of 104 Patients admitted to inpatient unit:
Delirium present on admission 44 (42%)
Delirium developed in 44 (42%) of remaining 60 patients
Delirium proximal to death: 46 (88%) of 52 deaths
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:

13. Reversibility 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 (

14. Key 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?

15. Dying Trajectories

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

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

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

19. Helpful Hints Best screening question: “What time is it?”
In assessing orientation to time, separate memory (date, year) from true orientation
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?

20. Regarding opioids
Consider:
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
Alternatives: hydromorphone, oxycodone, fentanyl
Evaluate for adjunctive therapy that might allow reduction in opioid dosing
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?
Re-orient – non-sedating neuroleptics
Sedate – benzodiazepines, sedating neuroleptics (chlorpromazine) barbiturates
Both – chlorpromazine

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

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

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