Terry Magee

1. 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.

2. Confusional States IN PALLIATIVE CARE PATIENTS may be • reversed • controlled • understood

3. EXPLORING FILTER CIRCUMSCRIBING AWARENESS THEORY Terry Magee Freelance palliative care educator terrymagee@hotmail.co.uk June 2009

4. “Reality Its not what happens its what you make of it.” (S Freud 1914)

5. 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.

6. CAUSES OF CONFUSIONAL STATES IN PALLIATIVE CARE PATIENTS Drug withdrawal • Benzodiazepines • Alcohol • Psychotropics

7. 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

8. CAUSES OF CONFUSIONAL STATES IN PALLIATIVE CARE PATIENTS Unrelieved anxiety and depression • Terminal agitation • Terminal restlessness • Panic • Unrelieved fear of dying • Parasuicidal actions

9. 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

10. 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

11. CAUSES OF CONFUSIONAL STATES IN PALLIATIVE CARE PATIENTS Infection Biochemical causes e.g. • Hypercalcaemia • Low sodium • Raised or lowered blood glucose • Raised blood urea

12. CAUSES OF CONFUSIONAL STATES IN PALLIATIVE CARE PATIENTS Organ failure • Kidneys • Liver • Heart • Lungs

13. CAUSES OF CONFUSIONAL STATES IN PALLIATIVE CARE PATIENTS Cerebral causes • Brain tumour • Raised intercranial pressure • Subdural Heamatoma • Paraneoplastic Dementia

14. 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 intellectualimpairment

15. 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

16. FILTER CIRCUMSCRIBING AWARENESS THEORY ENVIRONMENTAL STIMULI AWARENESS BODY STIMULI UNCONCIOUS STIMULI

17. AWAKE AWARENESS WHEN AWAKE MULTIPLE ENVIRONMENTAL STIMULI ENTERING AWARENESS MULTIPLE BODILY STIMULI ENTERING AWARENESS FEW UNCONCIOUS STIMULI BREAKING THROUGH

18. 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)

19. 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)

20. 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

21. 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.

22. 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.

23. 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

24. 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 ‘don’t let them arrest me, help me , get me out of here, I don’t 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.

25. CATEGORIES OF CONFUSIONAL STATES IN PALLIATIVE CARE

26. HELPING THE PATIENT Remember - reality lies in a person’s perceptions of an event or situation and not in the situation itself It’s not what happens it’s 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 patient’s 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

27. 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

28. Neckers Shifting Staircase