Altered States of Consciousness at the End-of-Life

James Hallenbeck, MDJames Hallenbeck, MD

Director, Palliative Care Services, VA Palo Director, Palliative Care Services, VA Palo Alto HCSAlto HCS

Assistant Professor of MedicineAssistant Professor of Medicine

Psychiatric Consultation

Situation: 

A psychiatric consultation is called for a patient with metastatic small cell carcinoma of the lung to determine “competency” (sic) regarding decision making and because the patient has been intermittently sleepy and agitated, calling out to unseen people.

 What approach do you take to such a consult?

Common Approach to Problem

Medical review - ? Brain metastasesMedical review - ? Brain metastases Medication reviewMedication review

On morphine sustained release 150 mg q 12 On morphine sustained release 150 mg q 12 with 30 mg morphine q2 for breakthrough painwith 30 mg morphine q2 for breakthrough pain

Decadron 6 mg qd.Decadron 6 mg qd. Metabolic review: at risk for hypercalcemia, Metabolic review: at risk for hypercalcemia,

hyponatremiahyponatremia Interview patient – assess orientation and perhaps Interview patient – assess orientation and perhaps

perform mini-mental status exam.perform mini-mental status exam.

By the end of this talk you should be able to

Discuss whether this might be normal dying Discuss whether this might be normal dying or notor not

Identify whether this is this a toxic delirium, Identify whether this is this a toxic delirium, a terminal delirium or a “normal altered a terminal delirium or a “normal altered state” of dyingstate” of dying

Discuss how these different states might be Discuss how these different states might be assessed and managed at the end-of-lifeassessed and managed at the end-of-life

Delirium – a problem of definitions…Latin – delirare to be deranged.Latin – delirare to be deranged.

Definition 1: “A state of temporary mental Definition 1: “A state of temporary mental confusion.”confusion.”

Definition 2: “A state of uncontrolled Definition 2: “A state of uncontrolled emotion, esp. excitement.” as in emotion, esp. excitement.” as in “Deliriously happy”“Deliriously happy”

Websters II New College Websters II New College DictionaryDictionary

DSMIV Definition of Delirium

Disturbance of consciousnessDisturbance of consciousness (reduced clarity of (reduced clarity of awareness of environment)awareness of environment)

Change in cognitionChange in cognition (memory deficit, disorientation, (memory deficit, disorientation, language disturbance) or the development of a perceptual language disturbance) or the development of a perceptual disturbance not otherwise accounted fordisturbance not otherwise accounted for

Development of the disturbance during a Development of the disturbance during a short time short time period with a tendency to fluctuateperiod with a tendency to fluctuate. .

Evidence that the disturbance is Evidence that the disturbance is caused by the direct caused by the direct physiological consequencesphysiological consequences of a general medical of a general medical condition.condition.

Altered State of Consciousness

Definition: Definition: A state of consciousness that is A state of consciousness that is other than normal wakefulnessother than normal wakefulness Can be good, neutral or bad qualitativelyCan be good, neutral or bad qualitatively

Bad altered states can be called deliriumBad altered states can be called delirium

Altered States at the End-of-Life

Common – prevalence of 25-85%Common – prevalence of 25-85% Exist along spectrums:Exist along spectrums:

Normal --------- ---------AbnormalNormal --------- ---------Abnormal Pleasant/ecstatic --------Very DisturbingPleasant/ecstatic --------Very Disturbing Reversible----------------IrreversibleReversible----------------Irreversible

Toxic (standard issue) Delirium

Reversible – often has correctable cause Reversible – often has correctable cause Associated with periodic agitated statesAssociated with periodic agitated states Psychedelic colors, rhythmic patterns Psychedelic colors, rhythmic patterns

(green ants, purple cows)(green ants, purple cows) Tends to occur earlier in the dying Tends to occur earlier in the dying

trajectorytrajectory Suspect if sudden change in functional and Suspect if sudden change in functional and

health statushealth status or with change in medication or with change in medication

Terminal Delirium

Occurs in patient identified as being very Occurs in patient identified as being very close (days) to deathclose (days) to death

Relatively irreversibleRelatively irreversible May mix components of toxic delirium with May mix components of toxic delirium with

dream-like stories involving peopledream-like stories involving people

Overlap in Altered States

Prospective Study of Delirium

Delirium present on admission 44 (42%)Delirium present on admission 44 (42%) Delirium developed in 44 (42%) of Delirium developed in 44 (42%) of

remaining 60 patientsremaining 60 patients Delirium proximal to death: 46 (88%) of 52 Delirium proximal to death: 46 (88%) of 52

deathsdeaths

Key FindingsOf 104 Patients admitted to inpatient unit:

Lawlor, P. and B. Gagnon (2000). "Occurrence, causes, and outcomes of delirium in patients with advanced cancer: a prospective study." Archives

of Internal Medicine 160: 786-794.

Reversibility in Delirium

Reversibility of delirium 46/94 episodes in 71 Reversibility of delirium 46/94 episodes in 71 patients 49%patients 49%

Univariate associates with delirium: Associated Univariate associates with delirium: Associated with reversibility: with reversibility: Opioids HR: 8.85 (2.13-26.74)Opioids HR: 8.85 (2.13-26.74) Dehydration: 2.35 (1.20-4.62)Dehydration: 2.35 (1.20-4.62)

Associated with irreversibility:Associated with irreversibility: Hypoxic encephalopathy: 0.32 (.15-.70) Hypoxic encephalopathy: 0.32 (.15-.70) Metabolic factors: 0.44 (0.21-.91Metabolic factors: 0.44 (0.21-.91

Key Questions regarding altered states What is the prognosis and dying trajectory?What is the prognosis and dying trajectory? Is the experience disturbing? (And Is the experience disturbing? (And whowho is is

disturbed – pt, family, staff)disturbed – pt, family, staff) If so, why?If so, why?

What are the goals of care?What are the goals of care?

Dying Trajectories

Distress in Altered States

WhoWho Patients Patients Families – may project concerns onto Families – may project concerns onto

patientpatient Clinicians – worries about decision Clinicians – worries about decision

making, communication, staff timemaking, communication, staff time

Goals of Care

Assume everybody wants to be comfortableAssume everybody wants to be comfortable Spectrum – comfort only – aggressive life-Spectrum – comfort only – aggressive life-

prolongationprolongation Have trade-offs been addressed Have trade-offs been addressed

Especially when distress-free alertness is Especially when distress-free alertness is impossible to achieve?impossible to achieve?

Distress in Altered States

What is distressing?What is distressing? ContentContent Lack of clarity – difficulty thinking, Lack of clarity – difficulty thinking,

communicatingcommunicating Level of consciousness – compare to Level of consciousness – compare to

desireddesired level of consciousness level of consciousnessHigherHigherLowerLower

Helpful Hints

Best screening question: “What time is it?”Best screening question: “What time is it?” In assessing orientation to time, separate In assessing orientation to time, separate

memory (date, year) from true orientationmemory (date, year) from true orientation Weigh benefits and burdens of what you Weigh benefits and burdens of what you

start and stopstart and stop Example – hydration might improve Example – hydration might improve

delirium, but is need to tie-down the delirium, but is need to tie-down the patient for an IV worth the price?patient for an IV worth the price?

Regarding opioids

Reducing opioid dose by 20-30% if patient has Reducing opioid dose by 20-30% if patient has zero to minimal pain, NOT stoppingzero to minimal pain, NOT stopping

Opioid rotation, when significant pain present, Opioid rotation, when significant pain present, especially when on morphineespecially when on morphine Alternatives: hydromorphone, oxycodone, Alternatives: hydromorphone, oxycodone,

fentanylfentanyl Evaluate for adjunctive therapy that might allow Evaluate for adjunctive therapy that might allow

reduction in opioid dosingreduction in opioid dosing

Consider:

REMEMBER: UNTREATED PAIN AND OPIOID WITHDRAWAL ALSO WORSEN DELIRIUM

Medications

Key question: To what extent are you trying Key question: To what extent are you trying to reorient, sedate or do both?to reorient, sedate or do both? Re-orient – non-sedating neurolepticsRe-orient – non-sedating neuroleptics Sedate – benzodiazepines, sedating Sedate – benzodiazepines, sedating

neuroleptics (chlorpromazine) neuroleptics (chlorpromazine) barbituratesbarbiturates

Both – chlorpromazineBoth – chlorpromazine

Visitations

Incidence: at least 25% of dying peopleIncidence: at least 25% of dying people Trans-cultural – not associated with religiosityTrans-cultural – not associated with religiosity Rarely disturbing to patientsRarely disturbing to patients Visitors:Visitors:

Deceased relatives and friendsDeceased relatives and friends Guardian spirits/angelsGuardian spirits/angels Babies and childrenBabies and children

Key Point: Seeing angels is not an indication for Haloperidol!

Common themes

Travel Travel Crossing-over, barriersCrossing-over, barriers ReunitingReuniting Unfinished businessUnfinished business Flash-backs and fearsFlash-backs and fears

SUMMARY

Altered states are commonAltered states are common Not all altered states are bad or abnormal or Not all altered states are bad or abnormal or

reversiblereversible Need for flexibility in managementNeed for flexibility in management More research is needed in both More research is needed in both

understanding and managing such statesunderstanding and managing such states