Skip to main content

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

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.
Anonymous said…
I have read your article. It's very nice. Thanks for sharing this...

Dentist Encino

Popular posts from this blog

Practical Advice for the End of Life: A Podcast with BJ Miller

This week we talk with BJ Miller, hospice and palliative care physician, public speaker, and now author with Shoshana Berger of the book "A Beginner's Guide to the End."

As we note on the podcast, BJ is about as close as we get to a celebrity in Hospice and Palliative Care.  His TED Talk "What Really Matters at the End of Life" has been viewed more than 9 million times.  As we discuss on the Podcast, this has changed BJ's life, and he spends most of his working time engaged in public speaking, being the public "face" of the hospice and palliative care movement.

The book he and Berger wrote is filled to the brim with practical advice.  I mean, nuts and bolts practical advice.  Things like:
How to clean out not only your emotional house but your physical house (turns out there are services for that!)Posting about your illness on social media (should you post to Facebook)What is the difference between a funeral home and mortuaryCan I afford to die?  …

Improving Advance Care Planning for Latinos with Cancer: A Podcast with Fischer and Fink

In this week's GeriPal podcast we talk with Stacy Fischer, MD and Regina Fink, RN, PhD, both from the University of Colorado, about a lay health navigator intervention to improve advance care planning with Latinos with advanced cancer.  The issue of lay health navigators raises several issues that we discuss, including:
What is a lay health navigator?What do they do?  How are they trained?What do lay health navigators offer that specialized palliative care doesn't?  Are they replacing us?What makes the health navigator intervention particularly appropriate for Latinos and rural individuals?  For advance care planning? Eric and I had fun singing in French (yes French, not Spanish, listen to the podcast to learn why).
Enjoy! -@AlexSmithMD




You can also find us onYoutube!



Listen to GeriPal Podcasts on:
iTunes Google Play MusicSoundcloudStitcher

Transcript

Eric: Welcome to the GeriPal podcast. This is Eric Widera.

Alex: This is Alex Smith.

Eric: And Alex, I'm really excited about toda…

The Dangers of Fleet Enemas

The dangers of oral sodium phosphate preparations are fairly well known in the medical community. In 2006 the FDA issued it’s first warning that patients taking oral sodium phosphate preparations are at risk for potential for acute kidney injury. Two years later, over-the-counter preparations of these drugs were voluntarily withdrawn by the manufacturers.  Those agents still available by prescription were given black box warnings mainly due to acute phosphate nephropathy that can result in renal failure, especially in older adults. Despite all this talk of oral preparations, little was mentioned about a sodium phosphate preparation that is still available over-the-counter – the Fleet enema.

Why Oral Sodium Phosphate Preparations Are Dangerous 

Before we go into the risks of Fleet enemas, lets spend just a couple sentences on why oral sodium phosphate preparations carry significant risks. First, oral sodium phosphate preparations can cause significant fluid shifts within the colon …