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

Caregiver evaluations

All the caregivers were legally designated as surrogate decision-makers. The team asked each caregiver at enrollment, “What would your preferred level of alertness for the patient be to ensure that the patient is comfortable?” Answers ranged from “Give no medication that would affect level of alertness” to “Give some medication to help sleep” to “Give medication to help sleep most of the time” to “Give medication to help the patient sleep all the time.”

The answers were designed to incorporate the patient’s state of restlessness/agitation and corresponded to RASS scores. The caregivers were asked for their perceptions of the patient’s ability to communicate coherently, to communicate meaningfully, and how frequently the patient had exhibited restlessness and/or agitation over the last 2 days. Each caregiver also was asked what percentage of time they spent with the hospitalized patient during their last 2 days. The researchers sought to determine the level of distress the patient’s agitation caused the caregiver.

Personalized Sedation Goals

The nurses preferred patients be more heavily sedated than did the caregivers. This study’s results demonstrated that the shorter the patient’s life expectancy, the deeper the sedation that was preferred. However, the researchers found nurses considered many patients to be undersedated.

As for the caregivers’ preferences, “as patients approach the final days of life, families often desire opportunities to express their love and to say goodbye. The ability for a patient to be able to hear, understand, and respond is of paramount importance,” Dr Hui explained.¹

This work suggests that defining a personalized sedation goal can be difficult. PSGs vary from person to person and incorporate agitation control, communication capacity, and the patient’s prognosis. The researchers call for further research to assist in managing agitated delirium in the sedated terminally ill cancer patient.

References

1. Hui D, De La Rosa A, Urbauer DL, Nguyen T, Bruera E. Personalized sedation goal for agitated delirium in patients with cancer: balancing comfort and communication. Cancer. Published online August 25, 2021. doi:10.1002/cncr.33876
2. Hui D, De La Rosa A, Wilson A, et al. Neuroleptic strategies for terminal agitation in patients with cancer and delirium at an acute palliative care unit: a single-centre, double-blind, parallel-group, randomized trial. Lancet Oncol. 2020;21(7):989-998. doi:10.1016/S1470-2045(20)30307-7
3. Sessler CN, Gosnell MS, Grap MJ, et al. The Richmond Agitation-Sedation Scale: validity and reliability in adult intensive care unit patients. Am J Respir Crit Care Med. 2002;166(10):1338-1344. doi:10.1164/rccm.2107138
4. Ely EW, Truman B, Shintani A, et al. Monitoring sedation status over time in ICU patients: reliability and validity of the Richmond Agitation-Sedation Scale (RASS). JAMA. 2003;289(22):2983-2991. doi:10.1001/jama.289.22.2983