Nurses More Likely To Prefer Deeper Sedation For Delirium in Patients with Cancer

Although both report distress from observing end-of-life delirium in patients with cancer, caregivers are more likely to prefer lighter sedation than nurses, according to a study published in Cancer. In addition, despite caregivers’ personal sedation goals (PSG), many patients were reportedly undersedated.

Overall, caregivers responded that they preferred a Richmond Agitation Sedation Scale (RASS) score between -1 and -3. In comparison, nurses responded that they tended to prefer a score between -3 and -4. Furthermore, although they reported greater delirium-related distress (P = .0006), caregivers had a greater tendency to choose lighter sedation options than nurses (OR, 4.8; P = .01). Nurses were more likely to prefer deeper sedation (P < .0001), particularly for patients no longer able to communicate (OR, 3.1-4.4; P < .0001) and who had a shorter life expectancy (OR, 1.7; P = .002).

“By examining PSGs in both study patients with agitated delirium and case vignettes, we found that caregivers preferred lighter sedation than nurses,” wrote David Hui, MD, MSc, Department of Palliative Care, Rehabilitation, and Integrative Medicine, The University of Texas MD Anderson Cancer Center, and colleagues. “Other PSG determinants identified in this study included delirium-related distress, a patient’s ability to communicate, and the life expectancy. The use of a PSG as a response criterion also highlighted that many patients were under sedated. Findings from this study may have implications for both clinical care and research involving patients with agitated delirium.”

The study asked 42 caregivers and 39 nurses to complete a survey assessing their loved one or patient’s level of delirium and their subsequent PSG as part of a preplanned secondary analysis of a double-blind randomized clinical trial examining the sedative effect of chlorpromazine and/or haloperidol in patients with agitated delirium.

Respondents were asked to select a PSG for the trial patient from 5 different options corresponding to RASS. They were also asked to select a PSG for 6 different possible scenarios that varied in agitation level, communication ability, and life expectancy. All caregiver participants were designated surrogate decision-makers with medical power of attorney.

Although both caregivers and nurses reported observing similar levels of patient agitation or restlessness, caregivers were more likely to report distress from the delirium than nurses (median, 6 vs 2; P = .0006). In addition, caregivers overall spent more time with the patient than nurses and were more likely to report that the patient was able to communicate coherently (P = .0498) and meaningfully (P = .02) than the nurses.

A preference for a deeper level of sedation was associated with higher levels of delirium-related distress (OR, 4.4; 95% CI, 1.1-17.2; P = .03). In addition, nurses demonstrated a higher preference for deeper sedation than the caregivers (OR, 4.8; 95% CI, 1.4-16.2; P = .01).

When responding to the potential scenarios, caregivers reported that they were more likely to prefer deeper sedation if their loved one was unable to communicate OR, 3.1- 4.4; P < .001) or if the expected survival time was days and not weeks (OR, 1.7; 95% CI, 1.2-2.5; P = .002).

However, in reality, caregivers were also more likely to report that their loved ones were able to coherently communicate. For instance, 15 caregivers responded that their patient was able to communicate with them “Most of the time” while only 5 nurses agreed with that statement.

“Interestingly, caregivers were also more likely than nurses to perceive that the patient was able to communicate meaningfully with them. Our findings provide insights into how much caregivers value retaining consciousness and communication abilities in patients with delirium,” the study authors wrote. “As patients approach the final days of life, families often desire opportunities to express their love and to say goodbye. The ability for a patient to be able to hear, understand, and respond is of paramount importance. “

Furthermore, 33% to 53% of patients were considered to be undersedated in comparison to the expressed sedation level outlined in the baseline PSG.

“Although oversedation is a commonly mentioned concern with sedatives and we used relatively high doses of neuroleptics in this trial,only 0% to 15% of the study patients were oversedated according to the study criteria. In contrast, the use of a PSG as a response criterion showed that 33% to 53% of the study patients were undersedated. This finding may explain why only 60% to 70% of the caregivers perceived the patient to be more comfortable,” explained study authors.

The study authors concluded by addressing the potential of PSG’s to help with debates on medication, dosage, and sedation levels. Although there will inevitably be variability between cases and preferred outcomes, the choices outlined in a PSG provide a framework for discussions between providers and caregivers.

Furthermore, the findings have highlighted a need to examine when caregivers would choose deeper sedation for their loved ones. Other relevant research would seek to assess the effect of higher does, more active dose titration, and/or novel interventions to achieve the desired level of sedation.

Reference

Hui D, De La Rosa A, Urbauer D, Nguyen T, Bruera E. Personalized sedation goal for agitated delirium in p0atients with cancer: balancing comfort and communication. Cancer. 2021;10.1002/cncr.33876. doi:10.1002/cncr.33876