Terminal Delirium Guidelines in Hospice

Terminal Delirium Guidelines

In the event the following S/S are being exhibited by the patient on hospice towards end of life,  consider that the patient may be experiencing terminal de-lirium:

S/S: Impaired level of consciousness, confusion, decreased awareness of surroundings/situation, restlessness, and/or agita-tion, moaning, groaning, irritation, restless, appearance of suffering, day/night reversal, delusions, hallucinations

Obtain orders and provide the following care accordingly:

Non-Pharmaceutical Interventions

Increase Staff Visits

Limit Visitors or Outside Stimulation

Assess for possible causes or contributing factors:

Hydration status
Urinary retention
Constipation with fecal impaction
Review Medication regimen
ETOH, nicotine, opioid, benzodiazepine, or other drug Hx
Withdrawal
Renal clearance
O2 deprivation (Hypoxemia)

Further assessments:

– Caregiver situation (competency, emotional & physical limitations) and it’s adequacy pertaining to the current status of the patient
– Changes in cognition of the patient
– Need for respite or continuous care
– Potential for placement at Inpatient facility (Polidori House)

Pharmaceutical Interventions (Note medication allergies and condition of pt)

– Haloperidol
– Lorazepam or Diazepam or Versed – Benzodiazepines are particularly important in patients who are in danger of experiencing withdrawal
– Morphine or Oxycodone instant release preparations

Medication Administration Orders

These orders are to be followed with the exception of occurrences where the patient has either an allergy to a specified medications, has had an adverse reaction to a medication, or the use of the medication is not advisable because of a diagnosis of a patient, or their past medical history prohibits the use of a medication. Where applicable, obtain orders for medications that may be reasonable substitute.

Obtain the order from HOH physician (attending or consulting) for the Terminal Delirium Protocol.

Dosing of medications for terminal delirium for control of the patients restlessness is to be administered per the following orders and should be given simultaneously if possible:

*If the patient’s comfort is not achieved with dosages administered as frequently as every 30 minutes, after two consecutive doses the administration frequency may be changed to every 15 minutes as needed. Remember to document this change, and to update the orders with this change if it is not already included.

For mild S/Sx of delirium

– Morphine 20mg/mL Oral concentrate preparation

-Give 5mg (0.25mL) by oral as often as every 30 minutes as needed until pt is no longer restless.

-Obtain orders to titrate dose to achieve the patients comfort if needed. It is preferable that orders for any additional parameters be requested when obtaining initial orders.

– Lorazepam 0.5mg tabs (or 2mg/mL solution if available)

-Administer 1mg by oral as often as every 30 minutes as needed until pt is no longer restless.

– Haldol 0.5mg tabs (or 2mg/mL oral solution)

-Give 1mg by oral as often as every 30 minutes as needed until pt is no longer restless.

For moderate to severe S/Sx of delirium

– Morphine 20mg/mL Oral concentrate preparation

-Give 5mg (0.25mL) by oral as often as every 30 minutes as needed until pt is no longer restless.

-Obtain orders to titrate dose to achieve the patients comfort if needed. It is preferable that orders for any additional parameters be requested when obtaining initial orders.

– Lorazepam 0.5mg tabs (or 2mg/mL solution if available)

-Administer 2mg by oral as often as every 30 minutes as needed until pt is no longer restless.

– Haldol 0.5mg tabs (or 2mg/mL oral solution)

-Give 2mg by oral as often as every 30 minutes as needed until pt is no longer restless.

Once the patients restlessness has ceased, pt is to be administered these medications every 3 – 4 hours in order to maintain the patient’s comfort.

In the event that the patient’s S/Sx do not cease within 3 hours, the available physician is to be contacted to report pt status and to obtain further orders.

Assess potential for Opioid Induced Hyperalgesia (OIH) which may occur with any dose of opioid a patient may be receiving. Report to physician.
Codeine, Hydrocodone, Morphine, Hydromorphone, Oxymorphone, Oxycodone

S/Sx of OIH (Opioid imduced hyperalgesia)
Increased pain in spite of increased pain meds (parenteral meds in renal failure)
Hyperexcitability
Myoclonus (twitching or jerking), delirium, seizures
Hyperreflexia,
Clonus (rapid succession of involuntary rhythmic dosiflexion or plantarflextion of the foot)
Wide spread pain
Allodynia (pain caused by stimulus that does not usually cause it) that is not associated with original pain

By

Ryan (Nurse at Polidori House HOH)

8-11-2014