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Managing delirium in terminally ill patients: perspective of palliative care nurse specialists

02 July 2020
Volume 25 · Issue 7

Abstract

Delirium occurs frequently at end of life. Palliative care clinical nurse specialists (CNSs) are involved in community palliative care provision. Many patients prefer being cared for at home, yet managing delirium in this setting presents unique challenges, potentially resulting in emergency hospital or hospice admission. We examined the experiences and practice of palliative care CNSs managing delirium in the community; 10 interviews were undertaken. Data were analysed using the framework approach. Challenges to delirium management in the community included limited time with patients, reliance on families and access to medications. Assessment tools were not used routinely; time limited visits and inconsistent retesting were perceived barriers. Management approaches differed depending on CNSs' previous delirium education. Strategies to prevent delirium were not used. Community delirium management presents challenges; support surrounding these could be beneficial. Routine assessment tool use and delirium prevention strategies should be included in further education and research.

Delirium is defined as a disturbance in attention and awareness that has developed over a short period of time, with disturbance in cognition not better explained by a pre-existing or evolving neurocognitive disorder (American Psychiatric Association (APA), 2013). Delirium is under-recognised due to the diversity and transient nature of the symptoms and because hypoactive delirium has the potential to be misdiagnosed as depression or fatigue (Spiller and Keen, 2006; Marchington et al, 2012).

Delirium is common across clinical settings (Pendlebury et al, 2015; Marcantonio, 2017) but is particularly common in palliative care, where its prevalence has been found to be up to 12% at initial community assessment and 88% in the final weeks of life (Watt et al, 2019). Medications, electrolyte imbalances, infection, organ failure and hypoxia may be implicated (Irwin et al, 2013). Delirium indicates a poor prognosis in palliative care patients, precipitating increased hospital admissions, morbidity and mortality (Bush et al, 2018), as well as communication loss (Lowe et al, 2016) and patient and family distress (Finucane et al, 2017).

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