Limit routine use of antipsychotic drugs to manage symptoms of delirium.
Effective screening, reversing the precipitants of delirium and providing a variety of supportive non-pharmacological interventions are crucial to addressing delirium in patients in palliative care settings.
Treatment with antipsychotic drugs should only be considered if patients with delirium are in distress and the cause of distress cannot be addressed through non-drug strategies. Although antipsychotics are commonly used in the management of delirium in palliative care patients, recent evidence on mild- to moderate-severity delirium suggests that antipsychotics are associated with both increased symptoms of delirium and reduced patient survival.
- Agar, Lawlor, et al, Efficacy of Oral Risperidone, Haloperidol, or Placebo for Symptoms of Delirium Among Patients in Palliative Care. JAMA Intern. Med. Jan 2017
- Bush, Tierney, Lawlor, Clinical Assessment and Management of Delirium in the Palliative Care Setting. Drugs. Oct 2017; 77:1623–1643
- Clinical Care Standards on Delirium. Australian Commission on Safety and Quality in Health Care. Jul 2016
Fellows from the Australian and New Zealand Society of Palliative Medicine and Australasian Chapter of Palliative Medicine (ANZSPM/AChPM) convened a working group to produce an EVOLVE list for palliative medicine. The Royal Australasian College of Physicians (RACP) assisted this working group in compiling a list of 15 clinical practices in palliative medicine which may be overused, inappropriate or of limited effectiveness in a given clinical context based on a desktop review of similar work done overseas.
This list was then sent out to all ANZSPM and AChPM members, seeking feedback on whether the items fully captured the concerns of clinicians in an Australasian palliative medicine context and if not, whether any items should be omitted and/or new items added. 40 responses to this email were received. Based on these, 3 items were removed leaving a shortlist of 12. An online survey was then sent to all ANZSPM and AChPM members asking respondents to rate each item against three criteria from 1 (lowest) to 5 (highest), and to nominate any additional practices worthy of consideration.
The criteria used to rate the practices were strength of evidence, significance in palliative care and whether palliative care physicians could make a difference in influencing the incidence of the practice in question. Based on the 114 responses to this survey, the top 5 were selected.
- 1 Do not delay discussion of and referral to palliative care for a patient with serious illness just because they are pursuing disease-directed treatment.
- 2 Limit routine use of antipsychotic drugs to manage symptoms of delirium.
- 3 Do not use oxygen therapy to treat non-hypoxic dyspnoea.
- 4 Target referrals to bereavement services for family and caregivers of patients in palliative care settings to those experiencing more complicated forms of grief rather than as a routine practice.
- 5 To avoid adverse medication interactions and adverse drug events in cases of polypharmacy, do not prescribe medication without conducting a drug regime review.