Bush Shirley H, Leonard Maeve M, Agar Meera, Spiller Juliet A, Hosie Annmarie, Wright David Kenneth, Meagher David J, Currow David C, Bruera Eduardo, Lawlor Peter G
Division of Palliative Care, Department of Medicine, University of Ottawa, Ottawa, Ontario, Canada; Bruyère Research Institute, Bruyère Continuing Care, Ottawa, Ontario, Canada.
Graduate Entry Medical School, University of Limerick, Limerick, Ireland.
J Pain Symptom Manage. 2014 Aug;48(2):215-30. doi: 10.1016/j.jpainsymman.2014.05.009. Epub 2014 May 28.
In end-of-life care, delirium is often not recognized and poses unique management challenges, especially in the case of refractory delirium in the terminal phase.
To review delirium in the terminal phase context, specifically in relation to recognition issues; the decision-making processes and management strategies regarding its reversibility; the potential refractoriness of delirium to symptomatic treatment; and the role of sedation in refractory delirium.
We combined multidisciplinary input from delirium researchers and knowledge users at an international delirium study planning meeting and relevant electronic database literature searches (Ovid Medline, Embase, PsycINFO, and CINAHL) to inform this narrative review.
The overall management strategy for delirium at the end of life is directed by the patient's prognosis in association with the patient's goals of care. As symptoms of delirium are often refractory in the terminal phase, especially in the case of agitated delirium, the judicious use of palliative sedation is frequently required. However, there remains a lack of high-level evidence for the management of delirium in the terminal phase, including the role of antipsychotics and optimal sedation strategies. For the family and health-care staff, clear communication, education, and emotional support are vital components to assist with decision making and direct the treatment care plan.
Further research on the effectiveness of delirium management strategies in the terminal phase for patients and their families is required. Further validation of assessment tools for diagnostic screening and severity measurement is needed in this patient population.
在临终关怀中，谵妄常常未被识别，并且带来独特的管理挑战，尤其是在终末期难治性谵妄的情况下。
回顾终末期背景下的谵妄，特别是关于识别问题；关于其可逆性的决策过程和管理策略；谵妄对症状性治疗的潜在难治性；以及镇静在难治性谵妄中的作用。
我们在一次国际谵妄研究规划会议上结合了谵妄研究人员和知识使用者的多学科意见，并进行了相关电子数据库文献检索（Ovid Medline、Embase、PsycINFO和CINAHL），以撰写本叙述性综述。
临终时谵妄的总体管理策略由患者的预后以及患者的护理目标决定。由于谵妄症状在终末期往往难以控制，尤其是在激越性谵妄的情况下，常常需要谨慎使用姑息性镇静。然而，对于终末期谵妄的管理，包括抗精神病药物的作用和最佳镇静策略，仍然缺乏高级别证据。对于患者家属和医护人员而言，清晰的沟通、教育和情感支持是协助决策和指导治疗护理计划的重要组成部分。
需要进一步研究终末期谵妄管理策略对患者及其家属的有效性。需要在这一患者群体中进一步验证用于诊断筛查和严重程度测量的评估工具。
