Delirium screening practice in specialist palliative care units: a survey

Abstract

ObjectivesDelirium is common and distressing in palliative care settings. This survey aims to describe current practice regarding delirium identification in specialist palliative care units (SPCU), such as inpatient hospices, in the UK.MethodsAn 18-item anonymous online survey was distributed by Hospice UK to their network of clinical leads (n=223), and to their research mailing list (n=228). The survey was also sent to the chair of the Hospice UK executive clinical leads forum for direct dissemination to forum representatives (n=20). Clinical leads and forum representatives were asked to distribute the survey to healthcare staff in their SPCUs.Results220 SPCU staff (48% nurses; 31% doctors; 10% healthcare assistants) completed the survey. Approximately half reported using clinical judgement alone to screen (97/204; 48%) and/or diagnose (124/220; 56%) delirium. Over a third used an assessment tool to screen for delirium (76/204; 37%). The majority (150/220; 68%) reported screening in response to clinical symptoms, while few reported routine on-admission (11/220; 5%) or daily-during-admission (12/220; 6%) screening. Most respondents had received some training on delirium (137/220; 62%). However, 130/220 (59%) said their SPCU did not have a training programme for delirium screening and only 79/220 (36%) reported that their SPCU had delirium clinical guidelines. The main barriers to routine screening included: lack of delirium training, lack of guidelines and complexity of patient’s conditions.ConclusionThere is variation in practice for delirium screening and diagnosis in SPCUs. Clinical guidelines for delirium, including consensus on which screening tools to use, are needed for this setting.

Delirium screening tools validated in the context of palliative care: A systematic review

“…10,22 Currently, the use of delirium screening tools in palliative care is varied and their utility is unclear. 1,23 A recent survey of UK and Irish palliative care physicians reported that 59% do not use a formal screening tool on patients admitted to inpatient palliative care units. 24 There is also variability in the timing of delirium screening and the training of staff performing screening which may limit delirium detection.…”

“…24 There is also variability in the timing of delirium screening and the training of staff performing screening which may limit delirium detection. 23 Furthermore, many delirium screening tools were not specifically developed for use in palliative care populations, who are often highly symptomatic, easily fatigued, and more likely to require non-verbal or observational assessments. 25,26 As a result, studies which validate delirium screening tools in other care settings may not be generalizable to palliative care settings.…”

Validation of the 4AT tool for delirium assessment in specialist palliative care settings: protocol of a prospective diagnostic test accuracy study

“…A recent survey of UK palliative care specialists reported the majority (68%) only screened for delirium when suspected clinically, and few (5%) screened routinely on admission to palliative care units 43 . Only a third of respondents (37%) used assessment tools to screen for delirium, despite international guidance advocating their use.…”

“…The 4AT is recommended for identifying patients with delirium 14 , and is currently used in palliative care settings [41][42][43] , but has not been validated for delirium screening in a terminally ill population.…”

The experience of delirium in palliative care settings for patients, family, clinicians and volunteers: A qualitative systematic review and thematic synthesis

“…16 Recent systematic reviews have found a lack of high quality evidence to support routine use of medication, including antipsychotics, for delirium. 17,18 However, surveys of palliative care clinicians have identified that current practice is poorly aligned with current evidence and guidelines; there is a lack of routine screening for delirium 19,20 and antipsychotics and benzodiazepines for delirium are more commonly used than by clinicians working in other specialties. 21…”