Department of Emergency Medicine, The University of Texas Health Science Center at Houston School of Nursing, Houston, Texas, USA
Departments of Palliative, Rehabilitation, and Integrative Medicine, The University of Texas Health Science Center at Houston School of Nursing, Houston, Texas, USA.
Oncologist. 2017 Nov;22(11):1368-1373. doi: 10.1634/theoncologist.2017-0115. Epub 2017 Aug 1.
To improve the management of advanced cancer patients with delirium in an emergency department (ED) setting, we compared outcomes between patients with delirium positively diagnosed by both the Confusion Assessment Method (CAM) and Memorial Delirium Assessment Scale (MDAS), or group A ( = 22); by the MDAS only, or group B ( = 22); and by neither CAM nor MDAS, or group C ( = 199).
In an oncologic ED, we assessed 243 randomly selected advanced cancer patients for delirium using the CAM and the MDAS and for presence of advance directives. Outcomes extracted from patients' medical records included hospital and intensive care unit admission rate and overall survival (OS).
Hospitalization rates were 82%, 77%, and 49% for groups A, B, and C, respectively ( = .0013). Intensive care unit rates were 18%, 14%, and 2% for groups A, B, and C, respectively ( = .0004). Percentages with advance directives were 52%, 27%, and 43% for groups A, B, and C, respectively ( = .2247). Median OS was 1.23 months (95% confidence interval [CI] 0.46-3.55) for group A, 4.70 months (95% CI 0.89-7.85) for group B, and 10.45 months (95% CI 7.46-14.82) for group C. Overall survival did not differ significantly between groups A and B ( = .6392), but OS in group C exceeded those of the other groups ( < .0001 each).
Delirium assessed by either CAM or MDAS was associated with worse survival and more hospitalization in patients with advanced cancer in an oncologic ED. Many advanced cancer patients with delirium in ED lack advance directives. Delirium should be assessed regularly and should trigger discussion of goals of care and advance directives.
Delirium is a devastating condition among advanced cancer patients. Early diagnosis in the emergency department (ED) should improve management of this life-threatening condition. However, delirium is frequently missed by ED clinicians, and the outcome of patients with delirium is unknown. This study finds that delirium assessed by the Confusion Assessment Method or the Memorial Delirium Assessment Scale is associated with poor survival and more hospitalization among advanced cancer patients visiting the ED of a major cancer center, many of whom lack advance directives. Therefore, delirium in ED patients with cancer should trigger discussion about advance directives.
为了改善急诊科（ED）中患有谵妄的晚期癌症患者的管理，我们比较了通过昏迷评估方法（CAM）和记忆谵妄评估量表（MDAS）均阳性诊断为谵妄的患者（A 组，n=22）、仅通过 MDAS 阳性诊断为谵妄的患者（B 组，n=22）和既未通过 CAM 也未通过 MDAS 阳性诊断为谵妄的患者（C 组，n=199）之间的结局。
在肿瘤学 ED 中，我们使用 CAM 和 MDAS 对 243 名随机选择的晚期癌症患者进行谵妄评估，并评估了预先存在的指示。从患者病历中提取的结局包括住院和重症监护病房（ICU）入院率以及总生存率（OS）。
A、B 和 C 组的住院率分别为 82%、77%和 49%（ = .0013）。A、B 和 C 组的 ICU 入住率分别为 18%、14%和 2%（ = .0004）。A、B 和 C 组具有预先存在的指示的比例分别为 52%、27%和 43%（ = .2247）。A 组的中位 OS 为 1.23 个月（95%置信区间 [CI] 0.46-3.55），B 组为 4.70 个月（95% CI 0.89-7.85），C 组为 10.45 个月（95% CI 7.46-14.82）。A 和 B 组之间的 OS 差异无统计学意义（ = .6392），但 C 组的 OS 超过了其他组（ < .0001）。
在肿瘤学 ED 中，使用 CAM 或 MDAS 评估的谵妄与晚期癌症患者的生存较差和住院增加有关。在 ED 中患有谵妄的许多晚期癌症患者缺乏预先存在的指示。应定期评估谵妄，并应触发对治疗目标和预先存在的指示的讨论。
谵妄是晚期癌症患者的一种毁灭性疾病。在急诊科（ED）早期诊断应能改善对这种危及生命的疾病的管理。然而，ED 临床医生经常会忽略谵妄，并且患有谵妄的患者的结局未知。这项研究发现，在主要癌症中心 ED 就诊的晚期癌症患者中，使用昏迷评估方法或记忆谵妄评估量表评估的谵妄与较差的生存率和更多的住院治疗有关，其中许多患者缺乏预先存在的指示。因此，癌症 ED 患者的谵妄应触发关于预先存在的指示的讨论。
