living your best to the end

Pain as a Cause of Agitated Delirium

Can’t you do something about her pain?”

An 85-year-old woman with multiple medical problems, including dementia, coronary artery disease, renal insufficiency, and peripheral vascular disease, was admitted to our hospital with urosepsis. Her hospital course was complicated by the development of dry gangrene of her left foot, Candida sepsis, Clostridium difficile enterocolitis, and multiple deep sacral and trochanteric pressure ulcers. When housestaff asked her son if he wanted us “to do everything,” he always answered yes.

She was able to be weaned from the ventilator and was transferred to a medical unit for continued treatment of hospital-acquired C difficile enterocolitis and wound care of her multiple stage 4 ulcers. She underwent 4 surgical debridements under general anesthesia in the operating room over a several-month period but remained persistently febrile despite continuous treatment with broad spectrum antibiotics.

The patient was withdrawn, tense, and turned toward the wall in a fetal position, but she screamed and cried out for her mother, moaned in pain, and tried to hit and strike out at the nurses when they performed her twice-daily dressing changes. She refused all efforts to feed her or offers of sips of fluid and received all nourishment and hydration through her feeding tube. She did not respond to the voice or touch of her son or grandsons when they visited.

On day 63 of her hospitalization, a palliative care consultation was requested by the nurse manager on the floor because of nursing staff distress about their perception of having to hurt the patient during dressing changes.

With the agreement of the attending physician, who had refused to give medication, on the grounds it would add to her confusion, , the palliative care team met with her son and her 2 grandchildren.

The son asked, “Can’t you do something about her pain?” The team reviewed the hospital course and clarified her diagnoses, prognosis, and what to expect in the future with her family.

The son asked for a trial of opioids, and his request was relayed to the attending physician, who agreed with the plan as long as the palliative care team took responsibility for prescribing and managing the opioid analgesic regimen, as he was not comfortable doing so.

Within 12 hours her mental status was improved enough that she recognized and smiled at her son and tolerated her dressing changes without evident distress or agitation.

Two days later the patient moved back to her original nursing home for continuing palliative and wound care from a hospice team, who managed her complex and twice-daily wound care and her pain management.

After she died months later, the family wrote to our CEO and called to express gratitude to the palliative care team for the comfort and peace that she experienced during the last few months of her life.

From :Journal of American Medical Associaiton (JAMA) 2012

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