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 2

On day 4, Nancy, Mrs Smith's daughter, came to visit after her father had called her to express his deep concern and worry about his wife's condition. The nursing staff was very adept at using the CAM to assess for delirium, and Mrs Smith was positive on the first assessment and continued to score positively for the next three assessments, done 8 hours apart. Nancy works with the older adult population in a hospital and immediately suspected that her mother was experiencing delirium. The primary care nurse talked at length with Nancy about the numerous predisposing risk factors that made her mother vulnerable to delirium, including advanced age, severity of illness, and comorbidities such as heart failure, diabetes, osteoarthritis, a history of urinary tract infections, hypertension, and diminished vision and hearing. Since her admission, Mrs Smith also had several precipitating risk factors for delirium, including numerous medications, immobilization, dehydration, malnutrition, an indwelling bladder catheter (risk for urinary tract infection), and sleep deprivation.
The nurse and Nancy discussed the numerous risk factors, and together, they developed a comprehensive plan of care. The care plan included safety measures to minimize the risk of falling, the discontinuation of the indwelling bladder catheter after a sample was sent for urinalysis, the continuous evaluation of the effectiveness and side effects of her pain medications, and respiratory treatments, including assistance in using the incentive spirometer. A chest x-ray was ordered, which revealed atelectasis in both lower lobes and consolidation on the left. Antibiotics were started because she had developed a urinary tract infection in addition to pneumonia. Nancy decided to stay with her mother in her hospital room to provide a familiar presence because that would help keep her mother calm and oriented. Nancy also helped physical therapy mobilize her mother to prevent functional decline. Nancy also assisted with and insisted that her mother use the incentive spirometer to expand her lungs and facilitate optimal oxygen exchange. With Nancy at her mother's bedside, food and fluids were provided continuously, facilitating her mother's recovery. Mrs Smith's husband brought in her hearing aids and glasses as well as familiar objects from home. A calendar and clock were placed where she could see them, and pictures of her grandchildren were put on the bedside table.
Mrs Smith had a written advance directive for healthcare and named her husband as durable power of attorney. Over the last couple of years, both Mr and Mrs Smith had many conversations about treatment options should they not be able to make their own decisions. Nancy and Mr Smith also made it clear to the medical and nursing staff that Mrs Smiths' wishes were not aggressive treatment, but palliative care. Advance directives were reviewed and orders were clarified to ensure that Mrs Smith's wishes were respected and supported. The palliative care team was consulted and became involved in Mrs Smith's care. The family, primary care provider, nurses, and palliative care team worked collaboratively with Mrs Smith and her family to ensure comfort and symptom control without aggressive treatment.

Nursing Interventions

Delirium is a medical emergency, and the goals of care are to (1) provide safety for the patient (2) identify the cause, and (3) treat the cause when possible or appropriate. Treatment focuses on the use of nonpharmacologic (nursing interventions) and pharmacologic therapy as needed, and the foundational principle is to treat the underlying cause. In palliative care, treatment of the cause or causes may not be feasible or possible related to the disease process, and the goals of care will change as the disease progresses. However; patient safety, patient well-being, and patient comfort are the cornerstone of excellent palliative nursing care.

The first priority for nursing is to maintain a safe, familiar environment for the patient, whether the setting is the hospital, hospice, long-term care, or home. Low nonglare lighting will prevent visual distortions. Surrounding the patient with familiar objects, such as family photos or favorite possessions, will provide comfort. Having a clock and calendar within sight will help the patient stay in the present. Any object of comfort should be placed within reach for reassurance. Reorientation to time, place, and person when and if appropriate is often helpful. Soft, soothing music may promote a healing environment. Gentle reorientation and reassurances that you will keep them safe may help. Glasses and hearing aids must be in working order and properly placed to maximize communication. Family members should be allowed to stay with the patient, especially if the surroundings are unfamiliar, such as in a hospital, hospice, or palliative care unit. Physical restraints should never be used because they are a precipitating risk factor for delirium and can escalate the behaviors rather than alleviate them. Education and support are imperative in assisting families through this difficult time, as they may not understand their loved one's behaviors. The bedside nurse is in the ideal situation to provide much needed comfort and assurance.

Familiar sights, sounds, smells, and touches may perhaps provide a sense of security and also assist in relieving some distress.[46] Aromatherapy may be useful in reducing anxiety in palliative care patients. For example, sandalwood oil may be effective in reducing anxiety when used as massage oil.[47] Gentle massage to the hands and/or feet may help relieve anxiety and quiet agitation.

Nurses intuitively know how to provide the best, evidence-based care for their patients and are therefore at the forefront of delirium prevention. Nurses are also vital to the well-being of their patients and derive great satisfaction when those same patients have improved and shown progress after an episode of delirium.

Pharmacological Treatment of Delirium

Treatment of delirium is aimed at removing or treating the underlying cause. The decision to treat with medication will depend on the patient's distress or the risk that the behaviors pose to self or others.[48] When using medications in the older adult population, it is imperative to start low and go slow and the medications are titrated to effect.[48] Haloperidol is most often recommended because it has fewer anticholinergic side effects, is less sedating, has fewer active metabolites, and rarely causes orthostatic hypotension or cardiovascular side effects.[46] Second-line atypical agents for treatment of delirium are olanzapine, risperidone, and quetiapine.[49] Benzodiazepines are not recommended for delirium in older adults because of the risk of rebound confusion, agitation, and risk for falls. These drugs can cause oversedation and exacerbate confusion.

In addition, haloperidol is contraindicated for patients with Parkinson disease or Lewy body dementia.

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