Preferred Sedation Levels for Agitated Delirium in Terminal Patients Vary Between Nurses and Caregivers

Caring for a person who is dying of a terminal disease can be a source of great distress whether one is a medical professional or the loved one of a patient with cancer. As the patient approaches the end of life, they often become agitated, lose the ability to communicate, and develop delirium, which leads to an increasingly fraught and anguished time for members of their care team. Is more sedation the answer? What medications, and at what levels, are most effective in these situations? David Hui, MD, MSc, and his team from the Department of Palliative Care, Rehabilitation and Integrative Medicine at the University of Texas MD Anderson Cancer Center conducted a study to evaluate nurses’ and caregivers’ personalized goals regarding sedation for these patients.¹

Delirium Is Not Static

For those at the end of life, delirium fluctuates according to several factors, including the amount of sedation a patient receives. One would think that an ideal situation involves deep sedation, but that is not always the case. In this study, Dr Hui and his group conducted a preplanned secondary analysis of a double-blind, randomized clinical trial that evaluated the sedating effects of chlorpromazine and/or haloperidol in patients with agitated delirium (Clinical Trials.gov Identifier: NCT03021486).^1,2

The researchers recruited 39 nurses and 42 caregivers to answer questions about their personalized sedation goals (PSGs) for terminally ill patients with cancer. The trial patients had been admitted to the acute palliative care unit with refractory agitation. All were already on low-dose haloperidol. They were randomly assigned to 1 of 3 groups: haloperidol dose escalation, neuroleptic rotation to chlorpromazine, or haloperidol and chlorpromazine given in combination until withdrawal, discharge, or death.¹

Patients qualified for the study if they were 18 years or older and had received a diagnosis of advanced cancer. They also had to have delirium diagnosed according to the criteria in DSM-5. Even though they were already on haloperidol, patients had to have a history of agitation leading to a score of +1 or higher on the Richmond Agitation Sedation Scale (RASS).

RASS is a validated 10-point numeric rating scale that ranges from –5 to +4. A negative score indicates levels of sedation: –1, drowsy; –2, light sedation; –3, moderate sedation; –4, deep sedation; and –5, unarousable. The score for an alert and calm patient is 0, with positive numbers indicating increasing levels of agitation: +1, restless; +2, agitated; +3, very agitated; and +4, combative.^3,4 The researchers noted that a RASS score must decrease by 4 points for a patient who is terminally agitated to be considered comfortable.¹

Nurse Evaluations

Nurses evaluated patients and assigned a RASS score at timed intervals immediately before administration of the study medication, at 0.5, 1, and 2 hours, then every 2 hours for the first 24 hours, and every 4 hours until death, discharge, or withdrawal.