Principles of managing delirium in palliative care
For management of agitation in the last days of life, see Agitation and restlessness in the last days of life.
Management of delirium in patients with palliative care needs depends on the severity of symptoms, potential benefits and burdens of treatment, and the patient’s prognosis, preferences and goals of care—see Principles of symptom management in palliative care. Key aspects of management are to:
- identify and treat cause(s) (if appropriate); despite the presence of progressive disease, addressing reversible causes may improve or resolve delirium
- start nonpharmacological management, including measures to prevent delirium, as soon as possible.
Patients with delirium should be cared for in a quiet setting where they can be closely and regularly observed and monitored—their behaviour may become erratic and unpredictable.
Interaction with patients with delirium requires a calm manner. Approach from the front, not the side—peripheral stimuli are more likely to be misinterpreted as hostile. Speak clearly and concisely, and provide frequent orientation (eg address patients by their preferred name, specify the date, time and location, introduce yourself and other staff members, explain your role and purpose of the visit). Patients are likely to be more settled in the presence of a familiar person (eg relative, friend, regular nursing staff member).
Patients with delirium can accidentally harm themselves by pulling out medical lines and tubes (eg endotracheal tubes, intravascular and urinary catheters). If possible, remove these devices, use less restrictive devices (eg subcutaneous infusion syringe driver instead of an intravenous line infusion pump), or consider ways to simplify medication management (using alternative routes [eg transdermal rather than parenteral drug administration]).
Delirium can deteriorate—be alert to signs of increasing agitation (eg persistently wanting to get out of bed and walk around) or behavioural disturbance (eg impulsivity, suspiciousness). If nonpharmacological interventions have not calmed a patient:
- consider allowing them to mobilise (if it is safe to do so)
- reassure them (this may involve the assistance of a familiar person)
- reassess the delirium diagnosis; ensure all potential causes have been identified and adequately addressed
- consider pharmacological management if they are significantly distressed or considered to be at imminent risk of harm to themselves or others.
Only use physical restraint as a last resort—it usually adds to the patient’s distress and disorientation, and can cause harm. If physical restraint cannot be avoided, see the Psychotropic guidelines for advice.
Explaining the causes and management of delirium is essential to support the patient and their family and carersFinucane, 2017. The Australian Commission on Safety and Quality in Healthcare (ACSQHC) Consumer Guide—Delirium Clinical Care Standard is a useful source of information.
At a minimum, review patients with delirium dailyAustralian Commission on Safety and Quality in Health Care (ACSQHC), 2021National Institute for Health and Care Excellence (NICE), 2019. Consider observations from carers over the 24-hour period because delirium has fluctuating symptoms. For more information on follow-up of patients with delirium, see the Psychotropic guidelines.
Caring for a patient with delirium, especially hyperactive, mixed or treatment-refractory delirium, can be very distressing for family, carers and healthcare professionals; see Family support in palliative care, Support for carers in palliative care and Healthcare professional wellbeing in palliative careFinucane, 2017.