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 ?