title: End-of-life delirium: issues regarding recognition, optimal management, and the role of sedation in the dying phase.
abstract: BACKGROUND
  In end-of-life care, delirium is often not recognized and poses unique management challenges, especially in the case of refractory delirium in the terminal phase.
  
  
  OBJECTIVE
  To review delirium in the terminal phase context, specifically in relation to recognition issues; the decision-making processes and management strategies regarding its reversibility; the potential refractoriness of delirium to symptomatic treatment; and the role of sedation in refractory delirium.
  
  
  METHODS
  We combined multidisciplinary input from delirium researchers and knowledge users at an international delirium study planning meeting and relevant electronic database literature searches (Ovid Medline, Embase, PsycINFO, and CINAHL) to inform this narrative review.
  
  
  RESULTS
  The overall management strategy for delirium at the end of life is directed by the patient's prognosis in association with the patient's goals of care. As symptoms of delirium are often refractory in the terminal phase, especially in the case of agitated delirium, the judicious use of palliative sedation is frequently required. However, there remains a lack of high-level evidence for the management of delirium in the terminal phase, including the role of antipsychotics and optimal sedation strategies. For the family and health-care staff, clear communication, education, and emotional support are vital components to assist with decision making and direct the treatment care plan.
  
  
  CONCLUSIONS
  Further research on the effectiveness of delirium management strategies in the terminal phase for patients and their families is required. Further validation of assessment tools for diagnostic screening and severity measurement is needed in this patient population.
authors.affiliation: Division of Palliative Care, Department of Medicine, University of Ottawa, Ottawa, Ontario, Canada; Bruyère Research Institute, Bruyère Continuing Care, Ottawa, Ontario, Canada. Electronic address: sbush@bruyere.org.
authors.forename: Shirley H
authors.initials: SH
authors.lastname: Bush
authors.affiliation: Graduate Entry Medical School, University of Limerick, Limerick, Ireland.
authors.forename: Maeve M
authors.initials: MM
authors.lastname: Leonard
authors.affiliation: Discipline, Palliative & Supportive Services, Flinders University, Adelaide, South Australia, Australia; South West Sydney Clinical School, University of New South Wales, Sydney, New South Wales, Australia; Department of Palliative Care, Braeside Hospital, HammondCare, Sydney, New South Wales, Australia.
authors.forename: Meera
authors.initials: M
authors.lastname: Agar
authors.affiliation: Palliative Medicine, Marie Curie Hospice, Edinburgh, United Kingdom.
authors.forename: Juliet A
authors.initials: JA
authors.lastname: Spiller
authors.affiliation: Faculty of Nursing, University of Notre Dame, Sydney, New South Wales, Australia.
authors.forename: Annmarie
authors.initials: A
authors.lastname: Hosie
authors.affiliation: McGill University, Montreal, Québec, Canada.
authors.forename: David Kenneth
authors.initials: DK
authors.lastname: Wright
authors.affiliation: Graduate Entry Medical School, University of Limerick, Limerick, Ireland.
authors.forename: David J
authors.initials: DJ
authors.lastname: Meagher
authors.affiliation: Discipline, Palliative & Supportive Services, Flinders University, Adelaide, South Australia, Australia.
authors.forename: David C
authors.initials: DC
authors.lastname: Currow
authors.affiliation: The University of Texas M. D. Anderson Cancer Center, Houston, Texas, USA.
authors.forename: Eduardo
authors.initials: E
authors.lastname: Bruera
authors.affiliation: Bruyère Research Institute, Bruyère Continuing Care, Ottawa, Ontario, Canada; Division of Palliative Care, Department of Medicine, Epidemiology and Community Medicine, University of Ottawa, Ottawa, Ontario, Canada; The Ottawa Hospital Research Institute, Ottawa, Ontario, Canada.
authors.forename: Peter G
authors.initials: PG
authors.lastname: Lawlor
mesh_terms: D003693:Delirium / Q000175:diagnosis* / Q000188:drug therapy; D006801:Humans; D006993:Hypnotics and Sedatives / Q000627:therapeutic use; D013727:Terminal Care / Q000379:methods*; D009626:Terminology as Topic
chemical_list: D006993:Hypnotics and Sedatives
keywords: Palliative care; delirium; end of life; hospice; sedation; terminal