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M
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CASE
HISTORY
CONFUSION IN PALLIATIVE CARE
Mr J.G. (John) is a 78-year-old man with a 2-year history of prostate cancer, with metastases to his spine and pelvis. He has until recently functioned at a high level, with apparently normal intellectual function according to his district nurse. He has severe pain in his back and left leg, in spite of palliative radiation therapy to known lumbar metastases. His GP has prescribed increasing doses of morphine.
John’s wife has diabetes and is registered blind. She is very dependent on John. His sister has been helping him by shopping and driving, as he is no longer coping with daily activities. His home care nurse is concerned that he is confused about time recently, he is not taking his medication as prescribed, and he seems vague and anxious. His pain remains moderate to severe, in spite of a steady increase in morphine doses. He has therefore agreed to be admitted to the local Cottage Hospital for symptom management. A niece has agreed to stay with his wife.
Following admission, John appears anxious, but quiet and compliant. He is oriented to person, time, and place on formal testing. He walks with a cane, and is independent with personal care. The nursing staff note that he tends to wander around, and sometimes appears to become lost on the ward. One nurse states that the patient is demented, while another is concerned that John is delirious.
QUESTION 1.
You are the nurse on duty. How would you assess John’s mental state?
QUESTION 2.
You are the doctor on duty and decide to come in to the Cottage Hospital to see John.
What are the possible causes of his recent behaviour changes.
QUESTION 3.
What investigations would you do?
QUESTION 4.
What non-pharmacological measures might help reduce his confusion?
QUESTION 5.
In addition to general measures and relief of the underlying cause of delirium, are there other specific treatments that you might use, as interim measures, to help control John’s delirious state?
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