Terry Magee

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Terry Magee

• Is an experienced palliative care nurse and
  educator who has worked in the speciality for
  over 25 years .Her work in developing countries
  and in the Uk hospice movement has seen her win a
  number of prestigious awards .Terry will help you
  to understand and respond with insight and
  sensitivity to patients with confusional states
  and those with existing mental health conditions.

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Confusional States IN PALLIATIVE CARE PATIENTS

• may be
• reversed
• controlled
• understood

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EXPLORING FILTER CIRCUMSCRIBING AWARENESS THEORY

• Terry Magee
• Freelance palliative care educator
• terrymagee_at_hotmail.co.uk
• June 2009

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Reality Its not what happens its what you make
of it. (S Freud 1914)
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ALTERED REALITYTHE PATIENT

• I was so unsure about where I was or what was
  happening.
• Inside my mind was screaming get out of here or
  you will die.
• I felt that the staff might inject me with
  poison, I felt afraid that they had mixed me up
  with someone else.
• It was like a waking dream and I felt helpless to
  do anything to stop myself or stop this
  disorganised thinking.
• I cannot remember a time in my life when my sense
  of reality was so bizarre.
• I seemed to lose my inhibitions, if I felt hot I
  saw no reason not to strip off.
• If I felt thirsty I could only see fluid in the
  flower vase and I would have drunk it.
• Looking back I am so grateful I did not disgrace
  myself.

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CAUSES OF CONFUSIONAL STATES IN PALLIATIVE CARE
PATIENTS

• Drug withdrawal
• Benzodiazepines
• Alcohol
• Psychotropics

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CAUSES OF CONFUSIONAL STATES IN PALLIATIVE CARE
PATIENTS

• Drugs
• Opioids
• Anticholinergics - Belladonna Alkaloids,
  Hyoscine
• Psychotropics
• Digoxin, Beta Blockers
• Anti ulcer drugs
• Anti convulsants
• Antibiotics - Penicillins, Cefalosporins,
  4Quinolones,
• Alcohol
• Antidepressants - Tryclicis
• Antiemetics - Antihistamines, Cyclizines,
  Haloperidol
• Antispasmodics - Glycopyrronium, Oxybutynin

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CAUSES OF CONFUSIONAL STATES IN PALLIATIVE CARE
PATIENTS

• Unrelieved anxiety and depression
• Terminal agitation
• Terminal restlessness
• Panic
• Unrelieved fear of dying
• Parasuicidal actions

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CAUSES OF CONFUSIONAL STATES IN PALLIATIVE CARE
PATIENTS

• Unrelieved pain
• retention of urine
• constipation
• metastatic pain
• RICP
• Chest pain giving rise to poor ventilation,
  giving rise to oxygen deprivation

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CAUSES OF CONFUSIONAL STATES IN PALLIATIVE CARE
PATIENTS

• Unfamiliar environment
• Admitted to hospice whilst very weak or unaware
  of deterioration
• Patient whose bed is moved close to death
• Patient who is not properly orientated to the
  hospice

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CAUSES OF CONFUSIONAL STATES IN PALLIATIVE CARE
PATIENTS

• Infection
• Biochemical causes e.g.
• Hypercalcaemia
• Low sodium
• Raised or lowered blood glucose
• Raised blood urea

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CAUSES OF CONFUSIONAL STATES IN PALLIATIVE CARE
PATIENTS

• Organ failure
• Kidneys
• Liver
• Heart
• Lungs

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CAUSES OF CONFUSIONAL STATES IN PALLIATIVE CARE
PATIENTS

• Cerebral causes
• Brain tumour
• Raised intercranial pressure
• Subdural Heamatoma
• Paraneoplastic Dementia

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SIMPLIFIED MENTAL TEST SCOREAsk Do you mind if
I test your memory?
Possible score 3 3 5 3 3 20

• Questions
• What is the date today?
• (day, month, year)
• What is the address here?
• I am going to test you with numbers
• can you take 7 away from 100? Again? Again?
• 93, 86, 79, 72, 65 then stop
• Can you tell me what this is called?
• (choose 3 simple objects such as a watch, a glass
  and a pencil)
• Name 3 imagined objects and ask the patient to
  remember and recall them (after the next task)
• I want you to take the paper in your right hand,
  fold it and place it on the table (3-stage
  command)
• Total Score
• Score of 10 or less indicates significant
  intellectual impairment

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UNDERSTANDING ALTERED MENTAL STATES IN THE
PALLIATIVE CARE PATIENT

• Filter circumscribing awareness theory
• Awareness is a brain function
• Awareness is a filter mechanism
• There are 3 sources of stimuli which enable us to
  become aware
• 1. We become aware of the environment
• 2. We become aware of the body
• 3. We become aware of material from our
  unconcious mind

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FILTER CIRCUMSCRIBING AWARENESS THEORY

• ENVIRONMENTAL
• STIMULI

AWARENESS
BODY STIMULI
UNCONCIOUS STIMULI
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AWAKE
AWARENESS WHEN AWAKE
MULTIPLE ENVIRONMENTAL STIMULI ENTERING AWARENESS
MULTIPLE BODILY STIMULI ENTERING AWARENESS
FEW UNCONCIOUS STIMULI BREAKING THROUGH
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ASLEEP

• AWARENESS
• WHEN ASLEEP

ONLY URGENT BODILY STIMULI BREAKING THROUGH
VERY FEW ENVIRONMENTAL STIMULI BREAKING THROUGH
MULTIPLE STIMULI FROM THE UNCONCIOUS BREAKING
THROUGH ( FORMING DREAMS)
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CONFUSED

• AWARENESS WHEN CONFUSED

BODILY STIMULI RANDOMLY BREAKING THROUGH
OCCASIONAL ENVIRONMENTAL STIMULI BREAKING THROUGH
MULTIPLE STIMULI FROM THE UNCONCIOUS BREAKING
THROUGH ( DREAM MATERIAL BECOMING CONSCIOUS
DURING NON- SLEEP)
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CONTEXT AND VOLUME(SET AND AROUSAL AWARENESS
FUNCTION)

• Set e.g. afraid
• Set e.g guilty
• Set e.g. pining
• Arousal e.g. deeply asleep
• Arousal e.g. drowsy and weak
• Arousal e.g. sedated

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COMBINING AWARENESS SET AND AROUSAL TO PRODUCE
THE DISTURBED RESPONSE

• 1. Filter allowing unconscious material to enter.
• 2. Set longing to be a child safe with mother.
• 3. Arousal influenced by weakness and medication.
• 4. Resulting experience is misperceiving the
  nurse for your mother and asking her for comfort.

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COMBINING AWARENESS SET AND AROUSAL TO PRODUCE
THE DISTURBED RESPONSE

• 1. Filter allowing unconscious material to enter
  .
• 2. Set feeling guilty
• 3. Arousal influenced by sedation
• 4. Resulting experience misperception of stranger
  as a policeman coming to arrest you.

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COMBINING AWARENESS SET AND AROUSAL TO PRODUCE
THE DISTURBED RESPONSE

• 1. Filter allowing unconscious material to enter
  .
• 2. Set afraid of dying
• 3. Arousal febrile and restless
• 4. Resulting experience misperception of burning
  to death, patient runs toward pond

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ALTERED MENTAL STATETHE RELATIVES

• My pain and sadness became suffused with anger at
  seeing my dignified intelligent mum lying naked
  in her bed eyes wide and frightened crying dont
  let them arrest me, help me , get me out of here,
  I dont want to die.
• How could I respond, what could I do?
• I felt so helpless, it was such a diminishment
  of all her humanity , I thought I had lost her
  before her body gave way to the cancer.
• It was so bloody unfair after all she had been
  through.
• It was only the sensitivity of the staff that
  held me in my despair.

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CATEGORIES OF CONFUSIONAL STATES IN PALLIATIVE
CARE
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HELPING THE PATIENT

• Remember - reality lies in a persons perceptions
  of an event or situation and not in the situation
  itself
• Its not what happens its what you make of it
• To empathise or relate is not the same as to
  collude
• Suspend judgement and put your own feelings to
  the background
• Listen carefully to the mood and the message of
  the patients experience
• Remember the therapeutic importance of company
• Scan the environment for possible misperceptions
  and dangers
• Use sedation only when your rationale is clearly
  patient centred
• Treat remedial cause treat if appropriate

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HELPING THE PATIENT

• Drug treatment - may be necessary to control
  symptoms, ensure safety and reduce disturbance
  for other patients.
• Principle - unless treating truly terminal
  agitation, a neuroleptic eg haloperidol, should
  be used initially as benzodiaxepines may sedate
  and paradoxically increase confusion.
• However if patients with an acute confusional
  state do not settle on haloperidol alone it may
  be necessary to add lorazepam, diazepam or
  midazolam.
• Terminal agitation, essentially diagnosed by
  excluding other (remediable) causes for acute
  confusion, is managed differently with midazolam
  as the drug of choice. Alternatively
  levomepromazine with or without midazolam can be
  used.
• Dosages Halperidol 10-30mg/24hours in divided
  dosage PO, SC bolus or CSCI, Midazolam
  10-60mg/24hours CSC!
• Levomepromazine 75-200mg/24hours CSC! With SC
  boluses 12.5-25mg

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Neckers Shifting Staircase