Page 1674 - Hematology_ Basic Principles and Practice ( PDFDrive )

1492 Part VIII Comprehensive Care of Patients with Hematologic Malignancies

patients can be agitated, hypoactive, or vacillate between the two. families, there is the possibility of planning ahead and choosing a
Symptoms of delirium include insomnia and daytime somnolence, setting for their child’s death—home, hospice, or hospital. The child
nightmares, restlessness or agitation, irritability, distractibility, may express a preference about where he or she feels safe or prefers
hypersensitivity to light and sound, anxiety, difficulty in concen- to be. Clear information about how the child is likely to die and
trating or marshaling thoughts, fleeting illusions, hallucinations professional support to validate the family’s choice are crucial. Even
and delusions, emotional lability, attention deficits, and memory more important is the explicitly stated “permission” from all members
disturbances. of the professional team that the family may change their choice freely
Validated delirium screening and severity tools are available, but at any time—that all options remain open and that no decision is
a comprehensive psychiatric evaluation is recommended to exclude irrevocable. In the past, siblings were rarely included in these discus-
other disorders, such as anxiety, minor depression, anger, dementia, sions and were often inadequately prepared for the eventuality of a
or psychosis. The cause of delirium is often never determined and is child dying at home. It is only recently that their voices are beginning
frequently multifactorial. Medications, especially opioids, nonsteroi- to be heard.
dal antiinflammatory drugs, and high-dose corticosteroids, commonly
contribute. Opioid-induced central nervous system toxicities are
more common in patients with renal dysfunction, on high doses of The Dying Child
opioids for long periods of time, with impaired cognition before
starting the opioids, with dehydration, or taking other psychoactive Therapist: Are you in any pain? Does anything hurt?
drugs. Other causes include metabolic abnormalities (hypercalcemia, Child: My heart.
hyperglycemia, or uremia), malnutrition, hypoxia, fever, infection, Therapist: Your heart?
uncontrolled pain, hepatic failure, primary brain tumor, and brain Child: My heart is broken. I miss everybody. 7
metastases.
Treatment for delirium should begin while the underlying cause(s) The distillation of anticipatory grief to its essence marks the immi-
are being treated. In addition to the medications listed in Table 92.3, nence of death. At times imperceptibly, at other times dramatically,
it is helpful to make the patient’s surroundings as familiar as possible, the child who has been living with the illness is transformed into a
restore aids to hearing and sight if they are needed, reorient the dying child.
patient frequently, and have family members, friends, or well-known The end point of the terminal phase is often marked by a turning
caregivers present. inward on the part of the child, a pulling back from the external
world. Cognitive and emotional horizons narrow, because all energy
MANAGEMENT CONCERNS DURING THE is needed simply for physical survival. A generalized irritability is not
uncommon. The child may talk very little and may even retreat from
LAST DAYS OF LIFE physical contact. Although such withdrawal is not universal, a certain
degree of quietness is almost always evident. The child is pulling into
Evidence suggests that children with advanced cancer who receive himself or herself, not away from others. This behavior is a normal
concurrent home-based palliative care have improved quality of life and expectable precursor to death—a form of preparation for the
26
at the end of life and are more likely to die at home. For some ultimate separation that lies ahead. 7

TABLE Treatment of Delirium (Adult Patient)
92.3
Drug Dose Comment
Typical and Atypical Antipsychotics
Haloperidol 1–4 mg PO, or 0.5–2 mg SQ, IV Do not exceed 20 mg in 24 hours
qhs or bid to tid Can add the same dose q4h prn
Maintain the patient on the effective dose (divided into a bid dose) for 3–4 days, then taper
over 1 week, as tolerated
Oral dose is 60–70% as potent as parenteral dose
Quetiapine 25–200 mg PO qhs Particularly useful in elderly patients with evening delirium
Start 25 mg hs for 3–4 days
Olanzapine 2.5–5 mg PO/SL Start 2.5–5 mg PO/SL qhs to bid (2.5 mg for elderly patients); can use q 4–6 hours prn
agitation
Maintain the patient on the effective dose (divided into a bid dose), then taper over 2 weeks,
as tolerated; also antiemetic
Aripiprazole 5 mg PO qd Do not exceed 30 mg
Does not prolong and may shorten QTc
Chlorpromazine 12.5–1000 mg PO/IV/PR Sedating; may cause significant hypotension
Benzodiazepines a
Lorazepam 0.5–1 mg q 1–2 hours Add to antipsychotic for patients with an agitated delirium
Tablets can be used PR for terminal delirium
Diazepam 5–10 pm PO bid Useful PR for patients unable to take oral medication
Clonazepam 0.5–5 mg PO/SL bid to tid Tablets have been used PR for terminal delirium; do not exceed 20 mg/24 hours
Midazolam 30–100 mg IV/SQ over 24 hours IV drip or subcutaneous infusion for terminal delirium
a Caution: Any benzodiazepine may exacerbate delirium, especially in older adults (>70 years of age).
q, Every; hs, at bedtime; d, day; bid, twice a day; tid, three times a day; prn, as needed; IM, intramuscularly; IV, intravenously; PO, orally; SL, sublingual; PR, rectally;
SL, sublingually; SQ, subcutaneously.
Modified from Abrahm JL: A physician’s guide to pain and symptom management in cancer patients, ed 3, Baltimore, 2014, Johns Hopkins University Press; and Miovic
M, Block S: Psychiatric disorders in advanced cancer. Cancer 110:1665, 2007.