Department of Palliative Care, Rehabilitation, and Integrative Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX, USA.
Ann Palliat Med. 2021 Jun;10(6):6979-6983. doi: 10.21037/apm-20-495. Epub 2020 Nov 19.
Most people have some idea of how they want to live their life; however, an estimated two-thirds of Americans have not completed their advance directives. This becomes an issue when up to 90% of patients develop delirium during their final days of life, at which point we depend on advance directives or surrogate decision-makers. Here, we present a case of terminal delirium in a patient with advanced cancer and a history of alprazolam abuse who had not discussed his end-of-life wishes with the medical team or with his estranged family. Treatment was provided to address reversible causes of delirium, including correcting electrolyte imbalances, urinary retention, and administered antibiotics for purulent otitis media. Hyperactive delirium was managed aggressively with intravenous neuroleptics and benzodiazepine, while keeping a balance between somnolence and control of agitative symptoms. Without knowing the patient's wishes, the family continued to struggle with decision making. However, with multidisciplinary team approach patients and caregivers' symptoms were better managed. Family then requested us to transfer him to a local hospice facility. The patient eventually passed away peacefully surrounded by his family members. This case highlights the importance of advance care planning, addressing emotional distress in estranged family members regarding symptom burden, and developing the appropriate treatment regimen for a delirious patient with a history of benzodiazepine abuse. Our case serves as a reminder of the support, guidance, and impact that inpatient palliative care teams can offer to both the patient and caregivers.
大多数人都对自己想要如何度过一生有一些想法；然而，据估计，有三分之二的美国人尚未完成他们的预先指示。当多达 90%的患者在生命的最后几天出现谵妄时，这就成了一个问题，此时我们依赖预先指示或替代决策人。在这里，我们介绍了一位患有晚期癌症和阿普唑仑滥用史的患者的终末期谵妄病例，该患者并未与医疗团队或疏远的家人讨论过他的临终愿望。治疗旨在解决谵妄的可逆转原因，包括纠正电解质失衡、尿潴留，并给予化脓性中耳炎的抗生素治疗。通过静脉注射神经阻滞剂和苯二氮䓬类药物积极治疗活跃性谵妄，同时在嗜睡和控制激动症状之间保持平衡。由于不知道患者的意愿，家人在决策方面仍感到困难。然而，通过多学科团队的方法，患者和护理人员的症状得到了更好的管理。家人随后要求我们将他转移到当地的临终关怀机构。患者最终在家人的陪伴下平静离世。这个病例强调了预先护理计划的重要性，解决了疏远的家庭成员对症状负担的情绪困扰，并为有苯二氮䓬类药物滥用史的谵妄患者制定了适当的治疗方案。我们的病例提醒人们，住院姑息治疗团队可以为患者和护理人员提供支持、指导和影响。
