Altered States of Consciousness
at the End-of-Life
James Hallenbeck, MD
Director, Palliative Care Services, VA Palo
Alto HCS
Assistant Professor of Medicine
Psychiatric Consultation
Situation:
A psychiatric consultation is called for a patient with
metastatic small cell carcinoma of the lung to
determine “competency” (sic) regarding decision
making and because the patient has been
intermittently sleepy and agitated, calling out to
unseen people.
What approach do you take to such a consult?
Common Approach to Problem
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Medical review - ? Brain metastases
Medication review
 On morphine sustained release 150 mg q 12
with 30 mg morphine q2 for breakthrough pain
 Decadron 6 mg qd.
Metabolic review: at risk for hypercalcemia,
hyponatremia
Interview patient – assess orientation and perhaps
perform mini-mental status exam.
By the end of this talk you should
be able to
Discuss whether this might be normal dying
or not
 Identify whether this is this a toxic delirium,
a terminal delirium or a “normal altered
state” of dying
 Discuss how these different states might be
assessed and managed at the end-of-life

Delirium – a problem of
definitions…
Latin
– delirare to be deranged.
Definition 1: “A state of temporary mental
confusion.”

Definition 2: “A state of uncontrolled
emotion, esp. excitement.” as in “Deliriously
happy”

Websters II New College
Dictionary
DSMIV Definition of Delirium
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Disturbance of consciousness (reduced clarity of
awareness of environment)
Change in cognition (memory deficit, disorientation,
language disturbance) or the development of a perceptual
disturbance not otherwise accounted for
Development of the disturbance during a short time
period with a tendency to fluctuate.
Evidence that the disturbance is caused by the direct
physiological consequences of a general medical
condition.
Altered State of Consciousness

Definition: A state of consciousness that is
other than normal wakefulness
 Can be good, neutral or bad qualitatively

Bad altered states can be called delirium
Altered States at the End-of-Life
Common – prevalence of 25-85%
 Exist along spectrums:
 Normal --------- ---------Abnormal
 Pleasant/ecstatic --------Very Disturbing
 Reversible----------------Irreversible

Toxic (standard issue) Delirium
Reversible – often has correctable cause
 Associated with periodic agitated states
 Psychedelic colors, rhythmic patterns (green
ants, purple cows)
 Tends to occur earlier in the dying trajectory
 Suspect if sudden change in functional and
health status or with change in medication
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Terminal Delirium
Occurs in patient identified as being very
close (days) to death
 Relatively irreversible
 May mix components of toxic delirium with
dream-like stories involving people
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Overlap in Altered States
Prospective Study of Delirium
Of 104 Patients admitted to inpatient unit:
Key Findings
Delirium present on admission 44 (42%)
 Delirium developed in 44 (42%) of
remaining 60 patients
 Delirium proximal to death: 46 (88%) of 52
deaths

Lawlor, P. and B. Gagnon (2000). "Occurrence, causes, and outcomes of
delirium in patients with advanced cancer: a prospective study." Archives of
Internal Medicine 160: 786-794.
Reversibility in Delirium
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Reversibility of delirium 46/94 episodes in 71
patients 49%
Univariate associates with delirium: Associated
with reversibility:
 Opioids HR: 8.85 (2.13-26.74)
 Dehydration: 2.35 (1.20-4.62)
Associated with irreversibility:
 Hypoxic encephalopathy: 0.32 (.15-.70)
 Metabolic factors: 0.44 (0.21-.91
Key Questions regarding altered
states
What is the prognosis and dying trajectory?
 Is the experience disturbing? (And who is
disturbed – pt, family, staff)
 If so, why?
 What are the goals of care?
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Dying Trajectories
Distress in Altered States
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Who
 Patients
 Families – may project concerns onto
patient
 Clinicians – worries about decision
making, communication, staff time
Goals of Care
Assume everybody wants to be comfortable
 Spectrum – comfort only – aggressive lifeprolongation
 Have trade-offs been addressed
 Especially when distress-free alertness is
impossible to achieve?
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Distress in Altered States
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What is distressing?
 Content
 Lack of clarity – difficulty thinking,
communicating
 Level of consciousness – compare to
desired level of consciousness
 Higher
 Lower
Helpful Hints
Best screening question: “What time is it?”
 In assessing orientation to time, separate
memory (date, year) from true orientation
 Weigh benefits and burdens of what you
start and stop
 Example – hydration might improve
delirium, but is need to tie-down the
patient for an IV worth the price?
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Regarding opioids
Consider:
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Reducing opioid dose by 20-30% if patient has
zero to minimal pain, NOT stopping
Opioid rotation, when significant pain present,
especially when on morphine
 Alternatives: hydromorphone, oxycodone,
fentanyl
Evaluate for adjunctive therapy that might allow
reduction in opioid dosing
REMEMBER: UNTREATED PAIN AND OPIOID
WITHDRAWAL ALSO WORSEN DELIRIUM
Medications
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Key question: To what extent are you trying
to reorient, sedate or do both?
 Re-orient – non-sedating neuroleptics
 Sedate – benzodiazepines, sedating
neuroleptics (chlorpromazine)
barbiturates
 Both – chlorpromazine
Visitations
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Incidence: at least 25% of dying people
Trans-cultural – not associated with religiosity
Rarely disturbing to patients
Visitors:
 Deceased relatives and friends
 Guardian spirits/angels
 Babies and children
Key Point: Seeing angels is not an indication for
Haloperidol!
Common themes
Travel
 Crossing-over, barriers
 Reuniting
 Unfinished business
 Flash-backs and fears
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SUMMARY
Altered states are common
 Not all altered states are bad or abnormal or
reversible
 Need for flexibility in management
 More research is needed in both
understanding and managing such states
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