Benzodiazepines and/or neuroleptics for the treatment of delirium in palliative care?-a critical appraisal of recent randomized controlled trials.

Delirium is a frequent condition in patients in a palliative care situation and most often associated with substantial burden or even danger for the persons concerned as well as caregivers and health-care-professionals. Despite the lack of randomized-controlled-trials (RCTs) benzodiazepines and neuroleptic agents are used extensively in palliative care for the pharmacological management of delirium. A focused review for RCTs assessing pharmacotherapy with benzodiazepines and neuroleptics for the treatment of delirium in patients treated in a palliative care or hospice setting published in 2017 was performed in PubMed. A narrative summary of the findings of the RCTs and practical recommendation are presented. Of 42 publications, two RCTs could be included. One trial assessed the use of lorazepam (in addition to haloperidol) in case of agitation, the other placebo or risperidone or haloperidol in delirious palliative care patients. Neither risperidone nor haloperidol were superior compared to placebo, but were associated with higher mortality and morbidity. Lorazepam (along with haloperidol) reduced agitation in patients with delirium compared to placebo (along with haloperidol), but was unable to reduce the severity and incidence of delirium. It is of importance to note that psychopharmacotherapy with antipsychotics is mainly indicated for the hyperactive form of delirium and psychotic symptoms (e.g., delusions or hallucinations) in the hyper- and hypoactive delirium. Severe agitation and aggressivity can be an indication for neuroleptics, when non-pharmacological interventions fail, whereas the use of benzodiazepines has to be limited to critical situations where neuroleptics cannot be applied and cases of delirium due to alcohol withdrawal. Both substances can aggravate, precipitate or mask delirium, result adverse events with substantial distress or unfavorable survival outcomes for the patients. Thus, they should only be used in severely symptomatic patients and the duration of the medication has to be limited in time. When delirium symptoms decay the psychopharmacotherapy has to be tapered. More important than psychopharmacotherapy, the thorough investigation and treatment of potentially reversible causes of delirium (e.g., pharmacotherapy, infection) and the routine identification of patients at risk for delirium along with prophylactic measures are essential. The recently published landmarks RCTs provide moderate evidence to adopt recommendations from other medical specialties (i.e., intensive care, geriatrics) to the field of palliative care.

Development and Use of the 'SENS'-Structure to Proactively Identify Care Needs in Early Palliative Care-An Innovative Approach.

Anticipatory planning for end of life requires a common language for discussion among patients, families, and professionals. Studies show that early Palliative Care (PC) interventions based on a problem-oriented approach can improve quality of life, support decision-making, and optimize the timing of medical treatment and transition to hospice services. The aim of this quality-improvement project was to develop a pragmatic structure meeting all clinical settings and populations needs. Based on the Medical Research Council (MRC) framework, a literature review identifying approaches commonly used in PC was performed. In addition, more than 500 hospital-based interprofessional consultations were analyzed. Identified themes were structured and compared to published approaches. We evaluated the clinical usefulness of this structure with an online survey among professionals. The emerged 'SENS'-structure stands for: Symptoms patients suffer from; End-of-life decisions; Network around the patient delivering care; and Support for the carer. Evaluation among professionals has confirmed that the 'SENS'-structure covers all relevant areas for anticipatory planning in PC. 'SENS' is useful in guiding patient-centered PC conversations and pragmatic anticipatory planning, alongside the regular diagnosis-triggered approach in various settings. Following this approach, 'SENS' may facilitate systematic integration of PC in clinical practice. Depending on clearly defined outcomes, this needs to be confirmed by future randomized controlled studies.

Dying is a transition.

PURPOSE: End-of-life care is designed as response to patients' verbally communicated needs. The concept of dying as a process would allow us to improve care. This concept may combine the needs of the dying, their outburst of emotions, gradual maturation, family processes, acute problems such as decreasing independence, with their inner experience and transformation of perception. In this study we explored dying patients' mode of perception, and deeper reasons for anxiety and existential suffering. METHODS: Dying inpatients of a major cancer centre treated by an interdisciplinary team were eligible. Psychotherapy records of cancer patients (course, reactions, discussions with nurses and physicians) provided the data. Participant observation and Interpretative Phenomenological Analysis (IPA) was applied. RESULTS: Our data (pilot study N=80/follow-up-study N=600) suggest that patients undergo transition into another state of consciousness beyond anxiety, ego, and pain. Transition appears to have three stages. Anxiety, struggle, denial/acceptance, family processes, and maturation (ie, finding meaning and dignity, coping with trauma) may depend on the transitional process and also hinder or facilitate this transitional process. CONCLUSIONS: Understanding dying as transition may induce a radical reinterpretation of what patients need.

Invasive palliative interventions: when are they worth it and when are they not?

In palliative cancer care situations, invasive palliative interventions are frequently considered. The perception of invasiveness has a wide range and is subjective. A structured palliative care approach can guide decisional processes. It may contain 6 key elements: (1) multidimensional and multiprofessional assessment patients current priorities, (2) quality of current symptom management for the potential target intervention, (3) documentation of potential reasons to reduce symptomatic medications, (4) cautious judgment if patients' potential clinical benefit can be extrapolated from published evidence, (5) a decisional process for the considered intervention (e.g., the 7 P's model: priority, price, probability, prognosis, progression, prevention, preferences), and (6) agreement on the goal of the intervention before the invasive intervention. The examples of pleural effusion and parenteral nutrition are briefly emphasized. Oncologists may be competent to foster patients' participation in decision making and to use available specialist palliative care competencies and those of other professions.