By Stacey Kusterbeck
In caring for patients at the end of life, Columba Thomas, MD, noticed that delirium often went unrecognized. In other cases, delirium was treated as a set of symptoms rather than as a syndrome. “Patients can easily end up quite sedated,” says Thomas, a postdoctoral associate and a bioethics fellow at Georgetown University’s Kennedy Institute of Ethics. A typical scenario is that a patient suddenly becomes agitated and looks quite uncomfortable. Clinicians caring for the patient treat the symptoms with antipsychotics and narcotics. “But they often don’t take a step back and say, ‘This patient is delirious. What is causing it, and what can we do about it?’” says Thomas.
Thomas and colleagues proposed a set of ethical rules to help clinicians manage the complex tradeoffs in ethical decision-making in such cases.1 “There are not easy, surefire solutions when patients develop delirium. But it is important for clinicians to appreciate the clinical and ethical complexity at hand and to think critically about better ways to prevent and treat delirium,” explains Thomas.
It is important for clinicians to recognize clinical and ethical challenges when older adults develop delirium at the end of life. Clinicians must think critically about how best to approach delirium based on a patient’s goals of care, according to the authors.
Some patients might want a basic workup to diagnose and treat a urinary tract infection — a common cause of delirium in older adults. Other patients may prefer to focus more exclusively on comfort. “Focusing on comfort and symptom management does not necessarily exclude other concerns, such as maintaining lucidity and functionality to the degree possible,” notes Thomas.
Ethicists can help to clarify the goals of care for a patient who develops delirium at the end of life. “Ethics consults can be helpful when there is uncertainty about how extensive of a diagnostic workup to do to consider reversible causes of delirium,” concludes Thomas.
- Thomas C, Alici Y, Breitbart W, et al. Drugs, delirium, and ethics at the end of life. J Am Geriatr Soc 2024; Jan 19. doi: 10.1111/jgs.18766. [Online ahead of print].
