Delirium: Opportunity for Comfort in Palliative Care

Jacqueline F. Close, PhD, RN, GCNS-BC, FNGNA; Carol O. Long, PhD, RN, FPCN

Disclosures

Journal of Hospice and Palliative Nursing. 2012;14(6):386-394. 

In This Article

Case Study: Part 1

You are the nurse assigned to Mrs Smith and have taken care of her for the 3 days. Mrs Smith is an 88-year-old woman with end-stage heart failure and has a history of type II diabetes mellitus, osteoarthritis, numerous urinary tract infections, and uncontrolled hypertension. She had been hospitalized four times over the past year for exacerbations of heart failure. She recently fell at home, fracturing her right hip, and underwent surgery torepair her hip. Two days postoperation, she became disoriented and frightened and would not follow nursing instructions. She periodically lashed out at her caregivers and did not recognize her husband of 65 years. She knew what year it was but could not tell where she was or how she got there. She needed constant reminders to stay in bed while she insisted on going to the bathroom (she still had an indwelling bladder catheter). Mrs Smith was awake most of the day and half of the night, vacillating between agitation and lethargy and not quite understanding why everyone was making her do things that hurt. She received pain medication around-the-clock and was able to report her pain levels when asked about them. She could not hear (her husband took her bilateral hearing aids home because he did not want her to lose them), and her eyeglasses were lost in the emergency department. She was unable to report her inability to hear or see well without her hearing aids and glasses.
On day 3 postoperation, Mrs Smith was exhausted and could not assist with her personal care. Her husband came to visit and tried to wake her, but she just opened her eyes and stared blankly at him. She had not used her incentive spirometer since early postoperation because it was on the floor under her bed, where it fell when she was looking for her glasses. Her husband was upset that his wife was not "herself" and he could not understand what was happening. Nurses complained that Mrs Smith was too hard to care for and that she must have "dementia."
Mrs Smith did not want aggressive treatment while hospitalized other than surgery for her hip fracture. She had gone through many hospitalizations and she told the nurses repeatedly that she "was tired of going to the hospital and being so sick," stating that she just wanted to go back home, surrounded by family and friends.
You suggest that she may have delirium because of her age, surgery, many comorbidities, and hearing and vision problems. The geriatrics educator trained in gerontology is contacted to hold an in-service on delirium.

During the impromptu staff in-service, the educator explains that the identification of delirium remains a clinical diagnosis, based on bedside observation of the patient and information from families and caregivers. According to Inouye et al,[4] the diagnosis of delirium should be based on careful bedside monitoring of the four key features of delirium, which include (1) acute onset and fluctuating course, (2) inattention, (3) disorganized thinking, and (4) altered level of consciousness.[5] In practice, primary care providers often fail to detect symptoms of delirium, with studies reporting that symptoms are documented in only 30% to 50% of affected patients.[6] The fluctuating symptoms that characterize delirium make it hard to detect, especially when primary care providers spend only brief intervals of time with patients. Nurses, on the other hand, spend more time at the bedside and therefore have the opportunity to anticipate, assess, and treat symptoms of delirium across all healthcare settings.

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