Discussion
Terminal delirium is experienced by many individuals in their last days to weeks of life. Symptoms can present as hyperactive (eg, agitation, hallucinations, heightened arousal) or hypoactive (lethargy, reduced motor activity, incoherent speech). Hyperactive terminal delirium is particularly problematic because it causes increased distress to the patient, family, and caregivers. Delirium can lead to safety concerns, such as fall risk, due to patients’ decreased insight into functional decline.
Many studies suggest both nonpharmacologic and pharmacologic treatments for nonterminal delirium that may also apply to terminal delirium. Nonpharmacologic methods, such as providing a quiet and familiar environment, relieving urinary retention or constipation, and attending to sensory deficits may help prevent or minimize delirium. Pharmacologic interventions, such as antipsychotics or benzodiazepines, may benefit when other modalities have failed to assuage distressing symptoms of delirium. Because hypoactive delirium is usually accompanied by somnolence and reduced motor activity, medication is most often administered to individuals with hyperactive delirium.
The VA provides long-term care hospice beds in their CLCs for veterans who are nearing end of life and have inadequate caregiver support for comprehensive end-of-life care in the home (Case Presentation). Because of their military service and other factors common in their life histories, they may have a unique set of characteristics that are predictive of developing terminal delirium. Awareness of the propensity for terminal delirium will allow for early identification of symptoms, timely initiation of nonpharmacologic interventions, and potentially a decreased need for use of antipsychotic medications.
In this study, as noted in previous studies, certain medications (eg, steroids, opioids, and anticholinergics) increased the risk of developing terminal delirium in this veteran population. Steroids and opioids are commonly used in management of neoplasm-related pain and are prescribed throughout the course of terminal illness. The utility of these medications often outweighs potential adverse effects but should be considered when assessing the risk for development of delirium. Anticholinergics (eg, glycopyrrolate or scopolamine) are often prescribed in the last days of life for terminal secretions despite lack of evidence of patient benefit. Nonetheless, anticholinergics are used to reduce family and caregiver distress resulting from bothersome sounds from terminal secretions, referred to as the death rattle.21
It was found that veterans in the control group lived longer on the hospice unit. It is unclear whether the severity of illness was related to the development of terminal delirium or whether the development of terminal delirium contributed to a hastened death. Veterans with a suspected infection were identified by the use of antibiotics on admission to the hospice unit or when antibiotics were prescribed during the last 2 weeks of life. Thus, treatment of the underlying infection may have contributed to the finding of less delirium in the control group.
More than half the veterans in this study received at least 1 dose of an antipsychotic in the last 2 weeks of life for the treatment of terminal delirium. The most commonly administered medication was haloperidol, given either orally or subcutaneously. Atypical antipsychotics were used less often and were sometimes transitioned to subcutaneous haloperidol as the ability to swallow declined if symptoms persisted.
In this veteran population, having a history of drug or alcohol abuse (even if not recent) increased the risk of terminal delirium. Comorbid cancer and history of mental health disease (eg, PTSD, schizophrenia, bipolar disorder) and Vietnam-era veterans with liver disease (primary cancer, metastases, or cirrhosis) also were more likely to develop terminal delirium.
Just as hospice care is being provided in community settings, nurses are at the forefront of symptom management for veterans residing in VA CLCs under hospice care. Nonpharmacologic interventions are provided by the around-the-clock bedside team to provide comfort for veterans, families, and caregivers throughout the dying process. Nurses’ assessment skills and documentation inform the plan of care for the entire interdisciplinary hospice team. Because the treatment of terminal delirium often involves the administration of antipsychotic medications, scrutiny is applied to documentation surrounding these medications.7 This study suggested that there is a need for a more rigorous and consistent method of documenting the assessment of, and interventions for, terminal delirium.