altered states of consciousness at the end-of-life
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Altered States of Consciousness at the End-of-Life. James Hallenbeck, MD Director, Palliative Care Services, VA Palo Alto HCS Assistant Professor of Medicine. Psychiatric Consultation. Situation: - PowerPoint PPT PresentationTRANSCRIPT
Altered States of Consciousness at the End-of-Life
James Hallenbeck, MDJames Hallenbeck, MD
Director, Palliative Care Services, VA Palo Director, Palliative Care Services, VA Palo Alto HCSAlto HCS
Assistant Professor of MedicineAssistant Professor of Medicine
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?
Common Approach to Problem
Medical review - ? Brain metastasesMedical review - ? Brain metastases Medication reviewMedication review
On morphine sustained release 150 mg q 12 On morphine sustained release 150 mg q 12 with 30 mg morphine q2 for breakthrough painwith 30 mg morphine q2 for breakthrough pain
Decadron 6 mg qd.Decadron 6 mg qd. Metabolic review: at risk for hypercalcemia, Metabolic review: at risk for hypercalcemia,
hyponatremiahyponatremia Interview patient – assess orientation and perhaps Interview patient – assess orientation and perhaps
perform mini-mental status exam.perform mini-mental status exam.
By the end of this talk you should be able to
Discuss whether this might be normal dying Discuss whether this might be normal dying or notor not
Identify whether this is this a toxic delirium, Identify whether this is this a toxic delirium, a terminal delirium or a “normal altered a terminal delirium or a “normal altered state” of dyingstate” of dying
Discuss how these different states might be Discuss how these different states might be assessed and managed at the end-of-lifeassessed and managed at the end-of-life
Delirium – a problem of definitions…Latin – delirare to be deranged.Latin – delirare to be deranged.
Definition 1: “A state of temporary mental Definition 1: “A state of temporary mental confusion.”confusion.”
Definition 2: “A state of uncontrolled Definition 2: “A state of uncontrolled emotion, esp. excitement.” as in emotion, esp. excitement.” as in “Deliriously happy”“Deliriously happy”
Websters II New College Websters II New College DictionaryDictionary
DSMIV Definition of Delirium
Disturbance of consciousnessDisturbance of consciousness (reduced clarity of (reduced clarity of awareness of environment)awareness of environment)
Change in cognitionChange in cognition (memory deficit, disorientation, (memory deficit, disorientation, language disturbance) or the development of a perceptual language disturbance) or the development of a perceptual disturbance not otherwise accounted fordisturbance not otherwise accounted for
Development of the disturbance during a Development of the disturbance during a short time short time period with a tendency to fluctuateperiod with a tendency to fluctuate. .
Evidence that the disturbance is Evidence that the disturbance is caused by the direct caused by the direct physiological consequencesphysiological consequences of a general medical of a general medical condition.condition.
Altered State of Consciousness
Definition: Definition: A state of consciousness that is A state of consciousness that is other than normal wakefulnessother than normal wakefulness Can be good, neutral or bad qualitativelyCan be good, neutral or bad qualitatively
Bad altered states can be called deliriumBad altered states can be called delirium
Altered States at the End-of-Life
Common – prevalence of 25-85%Common – prevalence of 25-85% Exist along spectrums:Exist along spectrums:
Normal --------- ---------AbnormalNormal --------- ---------Abnormal Pleasant/ecstatic --------Very DisturbingPleasant/ecstatic --------Very Disturbing Reversible----------------IrreversibleReversible----------------Irreversible
Toxic (standard issue) Delirium
Reversible – often has correctable cause Reversible – often has correctable cause Associated with periodic agitated statesAssociated with periodic agitated states Psychedelic colors, rhythmic patterns Psychedelic colors, rhythmic patterns
(green ants, purple cows)(green ants, purple cows) Tends to occur earlier in the dying Tends to occur earlier in the dying
trajectorytrajectory Suspect if sudden change in functional and Suspect if sudden change in functional and
health statushealth status or with change in medication or with change in medication
Terminal Delirium
Occurs in patient identified as being very Occurs in patient identified as being very close (days) to deathclose (days) to death
Relatively irreversibleRelatively irreversible May mix components of toxic delirium with May mix components of toxic delirium with
dream-like stories involving peopledream-like stories involving people
Overlap in Altered States
Prospective Study of Delirium
Delirium present on admission 44 (42%)Delirium present on admission 44 (42%) Delirium developed in 44 (42%) of Delirium developed in 44 (42%) of
remaining 60 patientsremaining 60 patients Delirium proximal to death: 46 (88%) of 52 Delirium proximal to death: 46 (88%) of 52
deathsdeaths
Key FindingsOf 104 Patients admitted to inpatient unit:
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: 786-794.
Reversibility in Delirium
Reversibility of delirium 46/94 episodes in 71 Reversibility of delirium 46/94 episodes in 71 patients 49%patients 49%
Univariate associates with delirium: Associated Univariate associates with delirium: Associated with reversibility: with reversibility: Opioids HR: 8.85 (2.13-26.74)Opioids HR: 8.85 (2.13-26.74) Dehydration: 2.35 (1.20-4.62)Dehydration: 2.35 (1.20-4.62)
Associated with irreversibility:Associated with irreversibility: Hypoxic encephalopathy: 0.32 (.15-.70) Hypoxic encephalopathy: 0.32 (.15-.70) Metabolic factors: 0.44 (0.21-.91Metabolic factors: 0.44 (0.21-.91
Key Questions regarding altered states What is the prognosis and dying trajectory?What is the prognosis and dying trajectory? Is the experience disturbing? (And Is the experience disturbing? (And whowho is is
disturbed – pt, family, staff)disturbed – pt, family, staff) If so, why?If so, why?
What are the goals of care?What are the goals of care?
Dying Trajectories
Distress in Altered States
WhoWho Patients Patients Families – may project concerns onto Families – may project concerns onto
patientpatient Clinicians – worries about decision Clinicians – worries about decision
making, communication, staff timemaking, communication, staff time
Goals of Care
Assume everybody wants to be comfortableAssume everybody wants to be comfortable Spectrum – comfort only – aggressive life-Spectrum – comfort only – aggressive life-
prolongationprolongation Have trade-offs been addressed Have trade-offs been addressed
Especially when distress-free alertness is Especially when distress-free alertness is impossible to achieve?impossible to achieve?
Distress in Altered States
What is distressing?What is distressing? ContentContent Lack of clarity – difficulty thinking, Lack of clarity – difficulty thinking,
communicatingcommunicating Level of consciousness – compare to Level of consciousness – compare to
desireddesired level of consciousness level of consciousnessHigherHigherLowerLower
Helpful Hints
Best screening question: “What time is it?”Best screening question: “What time is it?” In assessing orientation to time, separate In assessing orientation to time, separate
memory (date, year) from true orientationmemory (date, year) from true orientation Weigh benefits and burdens of what you Weigh benefits and burdens of what you
start and stopstart and stop Example – hydration might improve Example – hydration might improve
delirium, but is need to tie-down the delirium, but is need to tie-down the patient for an IV worth the price?patient for an IV worth the price?
Regarding opioids
Reducing opioid dose by 20-30% if patient has Reducing opioid dose by 20-30% if patient has zero to minimal pain, NOT stoppingzero to minimal pain, NOT stopping
Opioid rotation, when significant pain present, Opioid rotation, when significant pain present, especially when on morphineespecially when on morphine Alternatives: hydromorphone, oxycodone, Alternatives: hydromorphone, oxycodone,
fentanylfentanyl Evaluate for adjunctive therapy that might allow Evaluate for adjunctive therapy that might allow
reduction in opioid dosingreduction in opioid dosing
Consider:
REMEMBER: UNTREATED PAIN AND OPIOID WITHDRAWAL ALSO WORSEN DELIRIUM
Medications
Key question: To what extent are you trying Key question: To what extent are you trying to reorient, sedate or do both?to reorient, sedate or do both? Re-orient – non-sedating neurolepticsRe-orient – non-sedating neuroleptics Sedate – benzodiazepines, sedating Sedate – benzodiazepines, sedating
neuroleptics (chlorpromazine) neuroleptics (chlorpromazine) barbituratesbarbiturates
Both – chlorpromazineBoth – chlorpromazine
Visitations
Incidence: at least 25% of dying peopleIncidence: at least 25% of dying people Trans-cultural – not associated with religiosityTrans-cultural – not associated with religiosity Rarely disturbing to patientsRarely disturbing to patients Visitors:Visitors:
Deceased relatives and friendsDeceased relatives and friends Guardian spirits/angelsGuardian spirits/angels Babies and childrenBabies and children
Key Point: Seeing angels is not an indication for Haloperidol!
Common themes
Travel Travel Crossing-over, barriersCrossing-over, barriers ReunitingReuniting Unfinished businessUnfinished business Flash-backs and fearsFlash-backs and fears
SUMMARY
Altered states are commonAltered states are common Not all altered states are bad or abnormal or Not all altered states are bad or abnormal or
reversiblereversible Need for flexibility in managementNeed for flexibility in management More research is needed in both More research is needed in both
understanding and managing such statesunderstanding and managing such states