Impaired communication capacity and agitated delirium in the final week of terminally ill cancer patients: prevalence and identification of research focus

Abstract

The maintenance of intellectual activity is an important area in the "good death" concept. To clarify the communication capacity levels of terminally ill cancer patients in their final week, and to identify factors contributing to the development of communication capacity impairment and agitated delirium, a retrospective study was performed on 284 consecutive hospice inpatients. The data were collected by chart review, and two independent raters measured the degree of communication capacity and agitation in the last week, using multiple items from the Memorial Delirium Assessment Scale, the Communication Capacity Scale, and the Agitation Distress Scale. The percentages of patients who could achieve complex communication were 43%, 28%, and 13% at 5 days, 3 days, and 1 day before death, respectively. Agitated delirium was identified in 20%. Patients receiving opioids at a dose of > or =120 mg oral morphine equivalents/day one week before death were significantly unable to communicate clearly 3 days before death (0.48 [0.28-0.84], P=0.011). Male gender and the presence of icterus were identified as significant contributors to the development of agitated delirium (odds ratios [95% C.I.]=2.6 [1.4-5.0], P<0.01; 2.4 [1.3-4.4], P< 0.01). These findings demonstrate that communication capacity impairment and agitated delirium are frequently observed in terminally ill cancer patients, and are significantly correlated with a higher dose requirement of opioids and the presence of icterus. To explore the best management to maintain the intellectual activity of dying patients, research should focus on a homogeneous sample of patients receiving high-dose opioids and those with hepatic encephalopathy. In the meanwhile, clinicians should educate patients and family members about the nature of the dying process and help facilitate the completion of life purposes requiring complex mental activities before the latest stages of cancer.

A Retrospective Chart Review of Terminal Patients with Cancer with Agitation and Their Risk Factors

“…We identified agitated delirium in patients when the score on item 9 of the MDAS was 2 or more and it showed diurnal 1 Graduate School of Pharmaceutical Science, 2 Department of Palliative Medicine, 3 variation. Patients were divided into the agitated delirium and nonagitated delirium groups.…”

“…2 According to a report, agitated delirium was considered present when patients had scores of 2 or 3 on the psychomotor activity item of the Memorial Delirium Assessment Scale (MDAS) any day during the patient's final week. 3 In this study, we conducted a retrospective chart review of terminal patients with cancer who had agitated delirium at an acute care hospital during their last 3 months before death. We took the necessary measures such as maintaining the anonymity of the patients while presenting their data in order to conduct this study in accordance with the Osaka University Hospital Code of Ethics.…”

The Impact of a Tumor Diagnosis on Patients' Attitudes toward Advance Directives

“…It seems to be even lower than 20% in different European countries independent of the detailed legal situation [7,8,9,10,11,12]. In cancer patients, early AD consultations are of particular importance due to the imminent risk of impaired consciousness in advanced cases [13,14,15,16,17,18,19,20]. Recent studies showed that ADs improve the process of dying by reducing the patient's fear, the stress on relatives [21], and the physician's risk of burnout [22].…”

Missed Opportunities: Use of an End-of-Life Symptom Management Order Protocol among Inpatients Dying Expected Deaths

“…Often when these difficult decisions and clinical transitions are needed, the patient is quite sick and lacks the capacity to participate in end-of-life decision-making. [11][12][13] In these situations, physicians and surrogate decision makers may not be aware of patient preferences, making decisions more difficult. 14,15 Some findings suggest that the withholding and withdrawal of life-sustaining therapies is correlated with physician predictions of survival.…”