Saturday, March 2, 2013

Terminal Delirium: Fatalism and Intellectual Laziness?

(Picture from Wikimedia Commons)

In 1996, Catherine Sarkisian described the common geriatric diagnosis "failure to thrive" as the result of fatalism and intellectual laziness.  Fatalism, in the sense that there doesn't seem to be anything to be done about the condition (ie throw up your hands). Intellectual laziness, because in fact with some thoughtful clinical sleuthing, the cause of failure to thrive can often be traced to five potentially treatable conditions: impaired functioning, malnutrition, depression, and cognitive impairment.

So is terminal delirium the failure to thrive of palliative care?

Delirium can often be traced to a cause or constellation of causes, such as medication side effects, dehydration, unfamiliar environments, or lack of sleep.  Many of these conditions are treatable, for example by stopping the offending medications, encouraging fluid intake, encouraging family to stay, or improved sleep hygiene.

In palliative care do we too often jump to the diagnosis of terminal delirium?  Really, as Eric Widera pointed out the other day, a diagnosis of terminal delirium should only be made in retrospect, after a patient has died.  You don't know if it's terminal until it's terminal.

The risk of missing treatable causes of delirium is that the patient will lose the chance to spend their last moments of life conscious.  It may mean an earlier, preventable death, given deliriums strong association with dying.  For family members delirium feels like they've already lost their loved one, because the person they knew no longer seems present.

Fatalism and intellectual laziness indeed.

by: Alex Smith

3 comments:

mbevmdphd said...

This relates to the irksome diagnoses of terminal restlessness and terminal agitation. Many people seem comfortable treating these with benzodiazepines, while forswearing benzos for delirium. In fact, benzos are recommended for treatment of terminal restlessness: See http://hospicecare.com/resources/palliative-care-essentials/iahpc-essential-medicines-for-palliative-care/ AND http://www.ncbi.nlm.nih.gov/pubmed/23234300
Is terminal restlessness delirium or not? How are these "terminal" syndromes different from those observed at other times and why should they be treated any differently?

Anonymous said...

To a hammer, everything looks like a nail. Similarly, in Palliative Care, especially in Hospice, we must be careful not to assume that every agitated or delirious patiet is dying. However, I remember a papaer by Bruera that showed that even when we identify the cause of delirium, at least in advanced cancer patients, there is an18% chance of reversal(J Pain Symptom Manage. 1992:7:192-195). I think it is important to discuss the possibility of identifying reversible causes and the expected yield of the testing or the interventions.
While Ivan Illyich did gain a better understnding of death through suffering, he complained bitterly about not being engaged. "what tormented Ivan Illyich most was the deception, the lie, which for some reason they all accepted, that he was not dying but simply ill, and that he only need keep quiet and undergo a treatment and then something very good would result."
What I love about Hospice and Palliative Care is that it is not a cookie cutter specialty. We must meet each person, each family, where they are. We have to engage them in the decision making process and facilitate their choices.

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