Management

It is vital to explain to the patient and family the nature of the problem and all that is being undertaken.
Minimise staff changes and encourage the presence of family members where possible. Ensure a calm environment with frequent re-orientating measures.
Investigate and treat underlying cause(s).
Remove or reduce drugs with known CNS effects if clinically appropriate.
Oxygen may help if patient is cyanosed.
High dose dexamethasone (e.g. 16 mg stat) if cerebral tumour.
Sedation with benzodiazepines should be avoided initially as they can exacerbate the condition.
If the patient is symptomatic (nocturnal confusion, agitation, aggression, hallucinations, paranoia etc) and where there are no immediately reversible causes the best treatment is HALOPERIDOL:
- Haloperidol 0.5 mg - 1 mg subcut stat and repeat after 30 minutes if necessary - this dose can then be doubled after a further 30 minutes if no improvement.
- Large doses may be required (10-20 mg/24 hours subcut) to achieve a response.
- Aim for a regular BD dose or a continuous subcut infusion.
- The combination of haloperidol and clonazepam (or midazolam) is generally needed in the management of intractable delirium in the dying patient.

Note: In severe or complicated cases, an urgent referral to either the Psychiatric Consult or Palliative Care Service is recommended.


Information about this Canterbury DHB document (4143):
Document Owner:	Palliative Care Service (see Who's Who)
Issue Date:	July 2009
Next Review:	July 2010
Note: Only the electronic version is controlled. Once printed, this is no longer a controlled document.
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Have you read the Disclaimer? These pathways, for the care and management of patients within Canterbury, have been developed jointly by primary and secondary care clinicians. They provide guidance for General Practice teams to diagnose and manage patients suffering from a number of different conditions, and contain patient information resources. The pathways are maps of publicly-funded services accessed by referral from the community, and are strongly evidence based, but are not full clinical guidelines. As the pathways are suggested guidance only, while using them you must exercise your own clinical judgement and pertinent clinical data when treating your patient. This site is intended to be flexible and frequently updated. While every effort has been made to ensure accuracy, all information should be verified.

Topic Code: 4143