special subjects
Symptom Relief for the Dying Patient
Delirium and Confusion
Mental changes that can accompany the terminal stage of a disorder may distress patients and family members; however, patients are often unaware of them. Delirium is common. Causes include drugs, hypoxia, metabolic disturbances, and intrinsic central nervous system disorders. If the cause can be determined, simple treatment may enable patients to communicate more meaningfully with family members and friends. Patients who are comfortable and less aware of their surroundings may do better with no treatment. When possible, the physician should ascertain the preferences of patients and family members and use them to guide treatment. Simple causes of delirium should be sought. Agitation and restlessness often result from urinary retention, which resolves promptly with urinary catheterization. Confusion in debilitated patients is worsened by sleep deprivation. Agitated patients may benefit from antipsychotics or benzodiazepines; however, benzodiazepines may also cause confusion. Poorly controlled pain may cause insomnia or agitation. If pain has been appropriately controlled, a nighttime sedative may help. Family members and visitors may help lessen confusion by frequently holding the patient’s hand and repeating where the patient is and what is happening. Patients with severe terminal agitation resistant to other measures may respond best to barbiturates. However, family members should be told that after these drugs are used, patients may not regain the capacity for coherent interaction.Pentobarbital, a rapid-onset, short-acting barbiturate, may be given as 100 to 200 mg IM every 4 hours as needed.Phenobarbital, which is longer-acting, may be given orally, subcutaneously, or rectally. 