Agitation
Susan Emmens
Palliative Care Clinical Nurse Specialist
Restlessness – finding or affording no rest, uneasy, agitated. Constantly in motion fidgeting
Agitation – shaking, moving, mental or physical
Delirium – Disordered state of mind with incoherent speech, distressing hallucinations and paranoia may feature.
Definitions
Frequency
Restlessness and agitation occurs in 42% of
patients in the last 48 hours of life (Twycross &
Lichter, 1995)
Delirium develops in 80-90% of dying patients
at some stage n the last week of life, (Twycross
et al, 2009)
Assessment
Holistic assessment
Physical
Psychological
Spiritual
Social
What does the patient want
Start with obvious things!
Treat obvious causes and reassess
‘Think List’
Pain
Nausea
Bladder distension/
urinary retention
Nicotine/alcohol
withdrawal
Constipation
Dyspnoea
Infection
Unresolved issues
Medication
Spiritual distress
Psychological distress
Fear
Anxiety
Poor positioning
Psychological Distress
Past life experiences
Social and cultural background
Previous experience of illness
Nurses cannot always resolve this kind of suffering
Empathy personalised care can help
However working with distressed patients on a regular basis can have negative effects on nurses involved in their care
Impact for Family and Significant
Others
Remember what family and significant others
may be going through
Likely to be physically exhausted
Likely to be mentally irritated and frustrated
Distressed at sight of weak and wasted body
Undignified regression to incontinence
Not so long ago strong , active and a tower of
strength to others
Nursing Management Issues to
Consider
Patients individual perspective
Needs of family / significant others
Hydration
Medications
Environment
Appropriate & realistic interventions
Ethical & legal issues
Principles of Care
Problem solving approach to symptoms
Avoid unnecessary interventions
Review regularly
Maintain effective communication
Support family, significant others and each other
Try To
Keep calm and avoid confrontation
Respond to patients comments
Explain what is happening and why
Repeat important and helpful information
Key Points
Sedation can be an acceptable way to address
intractable symptoms which are distressing the patient
Drug use should be in proportion to the symptom –
criteria for success is the relief of the symptom not the
depth of the sedation
Negative issues related to sedation are about the lack of
individuality
Sedation can be justified ethically to control distress not
amenable to other treatments
Beneficence / Non Malificence
Balance between good and harm
Intentions
Acting in the patient’s best interests
Ethical Issues
4 principles approach
Respect for autonomy
Benificence
Non malificence
Justice
Beauchamp & Childress (2008)
Ethical issue relating to sedation – passive
euthanasia
Death hastening vs promotion of comfort
Palliative Sedation / Euthanasia
Palliative sedation Euthanasia
Intention Relief by reducing Relief by killing the
awareness patient
Method Dose titration Standard doses
Drugs Sedative Lethal cocktail
Proportionate Yes No
Criterion of Relief of distress Immediate death
success
Respect for Autonomy
Concept of informed consent
Allows people to be self determining in
decisions about their healthcare
HCP must respect decisions even when they are
unwise
Dilemma
Terminal sedation highlights the tensions
between promoting autonomy and acting in the
patient’s best interest
Is it ever acceptable to use sedation without the
patient’s consent ?
Arguments for using sedation
without consent
It relieves the patient’s distress
It allows the professional the space to review the
situation as it develops
It supports the relief of the suffering of others
close to the patient
It allows the professionals to act beneficently
Arguments against using
sedation without consent
It threatens patient autonomy – by reducing
competence with sedation the patient lacks the
opportunity to make decisions or communicate
Lack of control may escalate distress - we don’t
have evidence that sedation removes awareness
Uncertainty as to whether sedation relieves non
physical suffering
Some patients may wish to suffer
Key Points
Sedation can be an acceptable way to address
intractable symptoms which are distressing the
patient
Drug use should be proportionate to the
symptom – criteria for success is the relief of the
symptom not the depth of the sedation
Negative issues related to sedation are about the
lack of individuality
Sedation can be justified ethically to control
distress not amenable to other treatments
A diagnosis of Terminal Agitation can only be
made if reversible conditions are excluded or are
failing to respond to treatment
Medications
Confusional States /
Delerium
Haloperidol 0.5 – 1.5mg
s/c prn 4-6 hourly
Olanzapine 2.5mg Nocte
Restlessness /
Agitation
Midazolam 2.5 – 5mg s/c
prn 1-2 hourly
Levopromazine 6.25mg s/c
prn 4-6 hourly
Betty is a 76 yr old lady with breast cancer and
known liver metastases.
She has been admitted with increasing back pain,
reduced mobility and confusion.
Medications include: Zomorph 20mg BD,
Cocodamol x2 QDS , Oromorph prn
Betty is extremely agitated and restless, removing
covers and exposing herself, family are
obviously distressed seeing her like this.
George is a 81yr old gentleman with prostate
cancer and known bony metastases.
He is admitted with nausea and increasing
confusion.
He is agitated and disorientated, trying to drink
directly from his jug and has been incontinent
several times of large volumes of urine.
Gerald is a 64yr old gentleman with sigmoid
tumour, peritoneal disease and multiple liver
metastases.
He is barely responsive but denies pain or nausea.
He has no close relatives and no visitors
He is increasingly restless, pulling at covers and
trying to get out of bed.
Denise is a 44yr old lady with cervical cancer
She is admitted with pelvic pain and increasing
confusion.
On the ward she is agitated and restless, requesting
bedpans frequently but passing only small
amounts of urine.
Thank You for Listening
Any Questions ?
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