Agitation Susan Emmens Palliative Care Clinical Nurse Specialist
Definitions Restlessness finding or affording no rest, uneasy, agitated. Constantly in motion fidgeting Agitation shaking, moving, mental or physical Delirium Disordered state of mind with incoherent speech, distressing hallucinations and paranoia may feature.
Frequency Restlessness and agitation occurs in 42% of patients in the last 48 hours of life (Twycross & Lichter, 1995) Delirium develops in 80-90% of dying patients at some stage n the last week of life, (Twycross et al, 2009)
Assessment Holistic assessment Physical Psychological Spiritual Social What does the patient want Start with obvious things! Treat obvious causes and reassess
Think List Pain Nausea Bladder distension/ urinary retention Nicotine/alcohol withdrawal Constipation Dyspnoea Infection Unresolved issues Medication Spiritual distress Psychological distress Fear Anxiety Poor positioning
Psychological Distress Past life experiences Social and cultural background Previous experience of illness Nurses cannot always resolve this kind of suffering Empathy personalised care can help However working with distressed patients on a regular basis can have negative effects on nurses involved in their care
Impact for Family and Significant Others Remember what family and significant others may be going through Likely to be physically exhausted Likely to be mentally irritated and frustrated Distressed at sight of weak and wasted body Undignified regression to incontinence Not so long ago strong, active and a tower of strength to others
Nursing Management Issues to Consider Patients individual perspective Needs of family / significant others Hydration Medications Environment Appropriate & realistic interventions Ethical & legal issues
Principles of Care Problem solving approach to symptoms Avoid unnecessary interventions Review regularly Maintain effective communication Support family, significant others and each other
Try To Keep calm and avoid confrontation Respond to patients comments Explain what is happening and why Repeat important and helpful information
Key Points Sedation can be an acceptable way to address intractable symptoms which are distressing the patient Drug use should be in proportion to the symptom criteria for success is the relief of the symptom not the depth of the sedation Negative issues related to sedation are about the lack of individuality Sedation can be justified ethically to control distress not amenable to other treatments
Beneficence / Non Malificence Balance between good and harm Intentions Acting in the patient s best interests
Ethical Issues 4 principles approach Respect for autonomy Benificence Non malificence Justice Beauchamp & Childress (2008) Ethical issue relating to sedation passive euthanasia Death hastening vs promotion of comfort
Palliative Sedation / Euthanasia Palliative sedation Euthanasia Intention Relief by reducing Relief by killing the awareness patient Method Dose titration Standard doses Drugs Sedative Lethal cocktail Proportionate Yes No Criterion of Relief of distress Immediate death success
Respect for Autonomy Concept of informed consent Allows people to be self determining in decisions about their healthcare HCP must respect decisions even when they are unwise
Dilemma Terminal sedation highlights the tensions between promoting autonomy and acting in the patient s best interest Is it ever acceptable to use sedation without the patient s consent?
Arguments for using sedation without consent It relieves the patient s distress It allows the professional the space to review the situation as it develops It supports the relief of the suffering of others close to the patient It allows the professionals to act beneficently
Arguments against using sedation without consent It threatens patient autonomy by reducing competence with sedation the patient lacks the opportunity to make decisions or communicate Lack of control may escalate distress - we don t have evidence that sedation removes awareness Uncertainty as to whether sedation relieves non physical suffering Some patients may wish to suffer
Key Points Sedation can be an acceptable way to address intractable symptoms which are distressing the patient Drug use should be proportionate to the symptom criteria for success is the relief of the symptom not the depth of the sedation Negative issues related to sedation are about the lack of individuality Sedation can be justified ethically to control distress not amenable to other treatments
A diagnosis of Terminal Agitation can only be made if reversible conditions are excluded or are failing to respond to treatment
Medications Confusional States / Delerium Restlessness / Agitation Haloperidol 0.5 1.5mg s/c prn 4-6 hourly Midazolam 2.5 5mg s/c prn 1-2 hourly Olanzapine 2.5mg Nocte Levopromazine 6.25mg s/c prn 4-6 hourly
Betty is a 76 yr old lady with breast cancer and known liver metastases. She has been admitted with increasing back pain, reduced mobility and confusion. Medications include: Zomorph 20mg BD, Cocodamol x2 QDS, Oromorph prn Betty is extremely agitated and restless, removing covers and exposing herself, family are obviously distressed seeing her like this.
George is a 81yr old gentleman with prostate cancer and known bony metastases. He is admitted with nausea and increasing confusion. He is agitated and disorientated, trying to drink directly from his jug and has been incontinent several times of large volumes of urine.
Gerald is a 64yr old gentleman with sigmoid tumour, peritoneal disease and multiple liver metastases. He is barely responsive but denies pain or nausea. He has no close relatives and no visitors He is increasingly restless, pulling at covers and trying to get out of bed.
Denise is a 44yr old lady with cervical cancer She is admitted with pelvic pain and increasing confusion. On the ward she is agitated and restless, requesting bedpans frequently but passing only small amounts of urine.
Thank You for Listening Any Questions?