Research and Practice: Partners in Care Series
Delirium
Opportunity for Comfort in Palliative Care
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Jacqueline F. Close, PhD, RN, GCNS-BC, FNGNA
Delirium is a very common neuropsychiatric disorder
seen in the very ill and at the end of life and is
distressing to patients, families, and caregivers.
Although common, delirium is frequently misdiagnosed
and poorly managed. Too often, patients are merely
labeled as confused or agitated. This lack of
recognition, assessment, and treatment can lead to
poor outcomes, including functional decline, new
nursing home placement, and even death. Prompt
assessment, prevention, and both pharmacologic and
nonpharmacologic intervention by nurses and the
interdisciplinary team can significantly reduce distress,
assure comfort, and maximize safety in all care settings.
KEY WORDS
delirium, interventions, older adult, risk factors
elirium, or acute confusion, is a very common,
D serious, and potentially preventable neuropsy-
chiatric disorder that may occur in the very ill
and at the end of life as part of the dying process. Pa-
tients are often labeled as confused or agitated, and no
further assessment or evaluation is done. Delirium fright-
ens patients and families and also robs patients of valu-
able time to spend with loved ones. Patients remember
their episode(s) of delirium as very distressing, and delir-
ium is a negative experience for family members, care-
givers, and professional nurses alike.1 Delirium is associated
with emotional distress, as patients with delirium are often
anxious, angry, or depressed. Pain is much more difficult
to treat in patients with delirium, and those with hyperac-
tive delirium are at risk for falls and other types of inju-
ries.2 Delirium also interferes with the patient’s ability to
make choices about their care.3 Delirium is one of the ma-
jor contributors to poor health outcomes and often results
in the institutionalization of older adult patients.2
Jacqueline F. Close, PhD, RN, GCNS-BC, FNGNA, is District Clinical
Nurse Specialist for Geriatrics, Palomar Pomerado Health, San Diego, CA.
Carol O. Long, PhD, RN, FPCN, is Geriatric Consultant and Codirector,
Palliative Care for Advanced Dementia, Beatitudes Campus, Phoenix, AZ.
Address correspondence to Jacqueline F. Close, PhD, RN, GCNS-BC,
FNGNA, Palomar Health, 15255 Innovation Dr, San Diego, CA 92129
(Jacqueline.close@pph.org).
The authors have no conflict of interest to disclose.
DOI: 10.1097/NJH.0b013e31825d2b0a
386 www.jhpn.com
ƒ Carol O. Long, PhD, RN, FPCN
The purpose of this article is to provide an overview
of delirium, the prevalence, key features, risk factors, sub-
types, pathophysiology, assessment, and evidence-based
nursing interventions, both pharmacologic and nonphar-
macologic. A case study illustrates the challenges and op-
portunities in caring for hospitalized patients with delirium
who may require palliative care. While this article pro-
vides a general overview of delirium in the acute care set-
ting, delirium can occur anywhere in the continuum of care,
including the home, skilled nursing, outpatient settings, or
hospice settings.
CASE STUDY: PART 1
You are the nurse assigned to Mrs Smith and have taken
care of her for the 3 days. Mrs Smith is an 88-year-old
woman with end-stage heart failure and has a history of
type II diabetes mellitus, osteoarthritis, numerous urinary
tract infections, and uncontrolled hypertension. She had
been hospitalized four times over the past year for
exacerbations of heart failure. She recently fell at home,
fracturing her right hip, and underwent surgery torepair
her hip. Two days postoperation, she became disoriented
and frightened and would not follow nursing instructions.
She periodically lashed out at her caregivers and did not
recognize her husband of 65 years. She knew what year it
was but could not tell where she was or how she got
there. She needed constant reminders to stay in bed
while she insisted on going to the bathroom (she still had
an indwelling bladder catheter). Mrs Smith was awake
most of the day and half of the night, vacillating between
agitation and lethargy and not quite understanding why
everyone was making her do things that hurt. She
received pain medication around-the-clock and was able
to report her pain levels when asked about them. She
could not hear (her husband took her bilateral hearing
aids home because he did not want her to lose them), and
her eyeglasses were lost in the emergency department.
She was unable to report her inability to hear or see well
without her hearing aids and glasses.
On day 3 postoperation, Mrs Smith was exhausted and
could not assist with her personal care. Her husband
came to visit and tried to wake her, but she just opened
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 Research and Practice: Partners in Care Series
her eyes and stared blankly at him. She had not used her
incentive spirometer since early postoperation because
it was on the floor under her bed, where it fell when
she was looking for her glasses. Her husband was
upset that his wife was not ‘‘herself’’ and he could not
understand what was happening. Nurses complained
that Mrs Smith was too hard to care for and that she
must have ‘‘dementia.’’
Mrs Smith did not want aggressive treatment while
hospitalized other than surgery for her hip fracture. She
had gone through many hospitalizations and she told
the nurses repeatedly that she ‘‘was tired of going to the
hospital and being so sick,’’ stating that she just wanted
to go back home, surrounded by family and friends.
You suggest that she may have delirium because of
her age, surgery, many comorbidities, and hearing and
vision problems. The geriatrics educator trained in
gerontology is contacted to hold an in-service on delirium.
During the impromptu staff in-service, the educator
explains that the identification of delirium remains a clin-
ical diagnosis, based on bedside observation of the pa-
tient and information from families and caregivers.
According to Inouye et al,4 the diagnosis of delirium
should be based on careful bedside monitoring of the
four key features of delirium, which include (1) acute
onset and fluctuating course, (2) inattention, (3) disorga-
nized thinking, and (4) altered level of consciousness.5
In practice, primary care providers often fail to detect
symptoms of delirium, with studies reporting that symptoms
are documented in only 30% to 50% of affected patients.6
The fluctuating symptoms that characterize delirium make
it hard to detect, especially when primary care providers
spend only brief intervals of time with patients. Nurses,
on the other hand, spend more time at the bedside and
therefore have the opportunity to anticipate, assess, and
treat symptoms of delirium across all healthcare settings.
BACKGROUND
Prevalence and Incidence
The risk of developing delirium is positively associated
with age, frailty, and the number of chronic and acute
medical problems. In studies on delirium in hospital set-
tings, the prevalence and incidence rates of delirium dif-
fer in the published literature. Delirium has been reported
to be present in 14% to 24% of new admissions to the hos-
pital. The incidence of new cases of delirium has been
shown to be from 6% to 56% in hospitalized patients.7
In a 2003 study by Agnostini and Inouye,8 15% to 53%
of older postoperative adults were diagnosed with delir-
ium. In another study of patients in an intensive care unit,
Journal of Hospice & Palliative Nursing
70% to 87% of patients were diagnosed with delirium.9
Delirium also has been found in 51% to 85% of postYacute
care admissions.10 Patients with dementia or any cogni-
tive impairment have a very high incidence of delirium
superimposed on dementia, ranging from 22% to 89%.11
Delirium is the most common complication experienced
by patients with advanced illness, occurring in up to 85% of
patients in the last weeks of life.12 Delirium is also very
common in hospitalized patients, occurring in 26% to
44% of patients with late-stage cancer and up to 88% of
patients with terminal illness.13 Fang et al14 speculate that
the prevalence of delirium in cancer patients is from 11%
to 35%, and in terminal cancer patients, the prevalence
may be as high as 85%. In palliative care units, the prob-
ability of developing delirium can be as high as 88%.15
‘‘Terminal restlessness,’’ ‘‘nearing or near death aware-
ness,’’ and ‘‘terminal anguish’’ characterize delirium as ‘‘a
clinical spectrum of unsettled behaviors in the final days
of life.’’16(p345) Despite the fact that delirium is common in
older, very ill patients and as part of the dying process,
nurses can provide significant interventions to reduce dis-
tress and provide comfort to the patient and family. Delir-
ium in people who are terminally ill includes the detection
and elimination of the underlying cause (when possible)
and nonpharmacologic and pharmacologic treatments.
Patient and family education and reassurance are para-
mount to easing anxiety and providing for a therapeutic
environment.
Risk Factors
There are numerous risk factors for developing delirium.
These include predisposing risk factors and precipitating
risk factors.
Predisposing risk factors for delirium are risk factors
present before the patient becomes ill that may affect a
patient’s vulnerability for developing delirium. Some of
these predisposing risk factors include advancing age,
preexisting cognitive impairment, severity of illness, de-
pression, vision or hearing impairment, and functional
impairment.17 Other literature describes all of the same
predisposing risk factors but also includes male sex, de-
pression, alcohol abuse, abnormal serum sodium level,
and vision and hearing impairment.17-19 Inouye7 lists the
top predisposing factors for developing delirium as (1)
baseline cognitive impairment or dementia, (2) severe un-
derlying illness and comorbidity, (3) functional impair-
ment, and (4) advanced age.
Precipitating risk factors precede the development of
delirium and are any noxious insults or events that hap-
pen during an illness regardless of the setting. These risk
factors may include medication errors, immobilization,
dehydration, malnutrition, iatrogenic events, medical ill-
nesses, infections, metabolic abnormalities, alcohol or
drug withdrawal, environmental or psychosocial factors,
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 Research and Practice: Partners in Care Series
and the use of indwelling bladder catheters or physical re-
straints.7 Sleep deprivation, fecal impaction, and urinary re-
tention are frequent causes for delirium at the end of life.
Delirium is very common in patients with advanced
cancer and may involve multiple physiological causes
such as infection, end-stage organ failure, and adverse
medication events, and in some cases, it is caused by
paraneoplastic syndromes.20 In patients with cancer, de-
lirium may develop from structural or metabolic problems
and complicates the assessment and management of pain,
dyspnea, nausea, anxiety, and other symptoms.20,21
The onset of delirium is acute in most cases, and the
cardinal clinical symptoms include difficulty sustaining
attention, a fluctuating course, cognitive changes, and al-
tered level of consciousness.22 The patient is unable to
maintain attention for any period of time, and he/she
may be disoriented to time and place. Perception disor-
ders, hallucinations, identification mistakes, and distortion
in the size of objects are frequently noted.
Subtypes of Delirium
Delirium can manifest itself in three different subtypes:
hyperactive, hypoactive, and mixed delirium. Mixed de-
lirium includes elements of hyperactive delirium and hy-
poactive delirium.
Hyperactive delirium is characterized by agitation, hy-
pervigilance, restlessness, emotional instability, halluci-
nations, and delusions. Patients with hyperactive delirium
exhibit behaviors most commonly recognized as delirium,
and these behaviors include psychomotor hyperactivity
and excitability. These patients are easily identified by sev-
eral associated behaviors, such as fast or loud speech, irri-
tability, combativeness, impatience, swearing, singing,
laughing, uncooperativeness, euphoria, anger, wandering,
distractibility, and nightmares.23
Hypoactive delirium is characterized by withdrawal,
flat affect, apathy, lethargy, reduced alertness, and de-
creased responsiveness. The patient may be somnolent
and exhibit reduced psychomotor activity such as un-
awareness, decreased alertness, sparse or slow speech,
slowed movements, staring, and apathy. This is the ‘‘quiet’’
patient for whom the diagnosis is often missed.23 Patients
with hypoactive delirium are often misdiagnosed as de-
mented or depressed, and at the end of life, hypoactive
delirium not only can be mistaken for depression but is
also difficult to differentiate from opioid sedation.24
In palliative care settings, hypoactive delirium can be
misdiagnosed as depression or fatigue, particularly if a for-
mal assessment is not completed. Using valid and reliable
screening tools for palliative care patients can assist in di-
agnosing and differentiating delirium, especially when hy-
poactive delirium might otherwise go unrecognized.25
The third type of delirium is mixed delirium and in-
volves fluctuations between hyperactive and hypoactive
388 www.jhpn.com
behaviors. Mixed delirium is very difficult to diagnose
because of the changing presentation of the patient,
who alternates between a hyperalert and a hypoalert
state. An astute assessment and evaluation will capture
the mixed type of delirium, but this may go unnoticed
because of the fluctuations between the two states.
Regardless of the type of delirium the patient is experi-
encing, it is imperative that delirium is prevented, if pos-
sible, recognized, assessed, documented, and treated to
lessen the negative outcomes resulting from this syn-
drome. The associated poor outcomes of delirium are
very distressing to the patient and family members as well
as healthcare professionals, and nursing support is vital to
both the patient and family to lessen fears and anxiety.
Challenges
Delirium has a negative impact on patient outcomes. It is
associated with emotional distress, as people with delir-
ium are often anxious, angry, or depressed. Pain is much
more difficult to treat in patients with delirium, and pa-
tients with hyperactive delirium are at risk for falls and
other types of injuries.2 In addition, outcomes of patients
diagnosed with delirium during hospitalization include
an increased incidence of functional decline, new nurs-
ing home placement, and even death.26 Studies indicate
that delirium was associated with increased mortality at
hospital discharge and at 12 months postdischarge.27 De-
lirium was also associated with poor functional status
among patients with and without dementia.28 Healthcare
costs of patients with delirium are more than 22 times
the costs of patients without delirium, and the added finan-
cial burden can run from $16,303 to $64,421 per person.29
Clinical Assessment
The identification of delirium remains a clinical diagnosis,
based on bedside observation of the patient and infor-
mation from families and caregivers. According to Inouye
et al,4 the diagnosis of delirium should be based on care-
ful bedside monitoring of the four key features of delir-
ium, which include (1) acute onset and fluctuating course,
(2) inattention, (3) disorganized thinking, and (4) altered
level of consciousness. Many healthcare providers con-
sider delirium a common and serious problem, yet few
monitor for this condition, and most admit that it is under-
diagnosed.30 Fluctuating symptoms make delirium hard to
detect, especially when primary care providers spend
only brief intervals of time with patients. Nurses, on the
other hand, spend more time at the bedside and could
therefore assess for and treat symptoms of delirium across
healthcare settings.
Pathophysiology
The pathophysiology of delirium is not completely un-
derstood, and the proposed causes for delirium are
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 Research and Practice: Partners in Care Series

numerous (Table 1). It has been suggested in the litera-
ture that delirium may be a disturbance in cerebral oxygen-
ation, a disturbance in neurotransmission, a disturbance in
cytokine production, or a disturbance in plasma esterase
activity.31,32 Patients receiving palliative and end-of-life care
are particularly vulnerable for developing delirium.
Delirium can be caused by many different metabolic or
ischemic insults to the brain, such as hypoxemia, hyper-
capnia, hypoglycemia, or any major organ dysfunction.
Trauma, infection, surgery, or any other physical insult
to the body can lead to increased production of proin-
flammatory cytokines that, in susceptible patients, induces
delirium.32 Peripherally secreted cytokines can intensify
responses in the microglia (phagocytes that clean up
waste products from the nervous system) that in turn
cause severe inflammation of the brain.32 Proinflamma-
tory cytokine levels have been shown to be elevated in
patients with delirium.33
The Predictive Model of Delirium explains delirium as
the relationship between the vulnerability (predisposing
risk factors) of the hospitalized older adult and noxious
insults during (precipitating factors) hospitalization. This
relationship can contribute to the development of delir-
ium.7 This model considers the development of delirium
related to baseline patient vulnerability and precipitating
factors or noxious insults occurring during hospitaliza-
tion. Noxious insults are untoward negative incidents oc-
curring to a patient while the patient is hospitalized, such
as a urinary tract infection directly related to the pres-
ence of an indwelling urinary catheter or a patient fall
sustained during an episode of hyperactive delirium.
Highly vulnerable patients (those who have several risk
factors) may experience an episode of delirium with few
noxious insults. On the other hand, patients with low
vulnerability (few risk factors) may need to experience
several noxious insults to trigger an episode of delirium.7

TABLE 1 Differential Diagnosis of Delirium, With Interventions

Causes Differential Diagnosis Intervention
Infection HIV, sepsis, pneumonia Treat infections, use antibiotics as
needed, supportive care

Withdrawal Alcohol, barbiturate, sedative-hypnotic Discontinue or decrease medications,

monitor and treat withdrawal symptoms

Acute metabolic disorders Acidosis, alkalosis, electrolyte Treat metabolic/nutritional/fluid

disturbance, hepatic failure, renal failure disturbances, hepatic and renal failure

Trauma Closed head injury, heat stroke, Close monitoring, cool slowly for heat
postoperative state, severe burns stroke, supportive care

Central nervous system pathology Abscess, hemorrhage, hydrocephalus, Antibiotics, surgery, antiseizure
subdural hematoma, infection, seizures, medications, treat the cause
stroke, tumors, metastases, vasculitis,
encephalitis, meningitis, syphilis

Hypoxia Anemia, carbon monoxide poisoning, Provide oxygen, supportive care, blood
hypotension, pulmonary or product replacement
cardiac failure

Deficiencies Vitamin B12, folate, niacin, thiamine Treat /correct deficiencies

Endocrinopathies Hyperadrenocorticism/ Treat the cause, correct imbalances

hypoadrenocorticism, hyperglycemia/
hypoglycemia, myxedema,
hyperparathyroidism

Acute vascular conditions Hypertensive encephalopathy, stroke, Treat the cause

cardiac arrhythmia, shock

Toxins or drugs Prescription drugs, illicit drugs, pesticides, Discontinue or decrease medications
chemical solvents

Heavy metals Lead, manganese, mercury Clear from system

Adapted with permission from Delirium and Cognitive Impairment Study Group, Vanderbilt University Medical Center (January 15, 2012;
http://www.mc.vanderbilt.edu/icudelirium).

Journal of Hospice & Palliative Nursing www.jhpn.com 389

 Research and Practice: Partners in Care Series
Assessment and Measurement Tools
Screening Instruments
Screening instruments identify the presence of cognitive
impairment but do not diagnose delirium.34 The Mini-
Mental State Examination is used to evaluate cognitive
changes and assesses orientation, instantaneous recall,
short-term memory, attention, constructional capacities,
and use of language.35 The NEECHAM Confusion Scale
is used for a rapid assessment as well as monitoring of
acute confusion in hospitalized older individuals.36 The
Delirium Observation Screening Scale is an assessment
tool designed to assist nurses in the early recognition of
delirium during regular care and is based on the Diag-
nostic and Statistical Manual of Mental Disorders, Fourth
Edition (DSM-IV), criteria for delirium.37 The Nursing De-
lirium Screening Scale is an observational five-item instru-
ment designed to be completed in 1 minute and is a
simple, yet accurate, continuous, ‘‘around-the-clock symp-
tom monitoring.’’38(p373) The tool of choice should be the
one best suited for the patient population being screened.
Diagnostic Instruments
Diagnostic instruments are an adjunct to clinical and cog-
nitive evaluation and help in diagnosing delirium.39 The
Confusion Assessment Method (CAM) is a diagnostic tool
designed for use by a nonpsychiatrically trained inter-
viewer to identify and recognize delirium quickly and ac-
curately both at the bedside and in research settings.5
The CAM is used as the primary tool to screen residents
in nursing homes.40 The Delirium Rating Scale-Revised-98
is used both as a diagnostic and severity-based instrument
based on the DSM-IV and common symptoms found in
delirious patients. This is used to rate the severity of delir-
ium over time and differentiates patients with delirium from
patients with dementia, schizophrenia, and depression.41,42
Severity of Symptom Instruments
These scales are used to rate the severity of the symp-
toms of delirium. The Memorial Delirium Assessment
Scale (MDAS) is a brief, reliable tool for assessing delir-
ium severity among medically ill, adult patients and can
be accurately scored by multiple raters. The MDAS is
highly correlated with existing measures of delirium
and cognitive impairment.42 The Bedside Confusion
Scale (BCS) is used for continuous observation of an al-
teration in attention, with or without a change in level of
consciousness. The BCS is designed for the palliative
medicine population, requires minimal training, and takes
approximately 2 minutes to complete.43 The Delirium In-
dex measures the severity of symptoms of delirium and
is based on observation of the patient, without additional
information from informants.44 (For additional details on
the psychometric properties of each instrument, consult
390 www.jhpn.com
the detailed reference list at the end of this article). Table 2
describes the assessment tools used in screening, diagnos-
ing, and determining the severity of delirium.
Delirium is very common at the end of life, but if as-
sessed and identified early, interventions may be put in
place to lessen the symptoms and ensure the patient’s
comfort along with patient and family well-being. The
most important approach to treatment of delirium is to
reverse underlying causes if possible, and in palliative
care, the goals of treatment for delirium are balanced
with a caring approach, providing a safe environment,
and avoiding uncomfortable interventions. Addressing
only one of the factors contributing to the delirium is
not likely to help improve the delirium. However, a mul-
tifactorial intervention strategy that addresses as many
predisposing and precipitating factors as possible sup-
ports positive nursing care.
CASE STUDY: PART 2
On day 4, Nancy, Mrs Smith’s daughter, came to visit
after her father had called her to express his deep
concern and worry about his wife’s condition. The
nursing staff was very adept at using the CAM to assess
for delirium, and Mrs Smith was positive on the first
assessment and continued to score positively for the next
three assessments, done 8 hours apart. Nancy works
with the older adult population in a hospital and
immediately suspected that her mother was experiencing
delirium. The primary care nurse talked at length with
Nancy about the numerous predisposing risk factors that
made her mother vulnerable to delirium, including
advanced age, severity of illness, and comorbidities such
as heart failure, diabetes, osteoarthritis, a history of
urinary tract infections, hypertension, and diminished
vision and hearing. Since her admission, Mrs Smith
also had several precipitating risk factors for delirium,
including numerous medications, immobilization,
dehydration, malnutrition, an indwelling bladder catheter
(risk for urinary tract infection), and sleep deprivation.
The nurse and Nancy discussed the numerous risk
factors, and together, they developed a comprehensive
plan of care. The care plan included safety measures to
minimize the risk of falling, the discontinuation of the
indwelling bladder catheter after a sample was sent for
urinalysis, the continuous evaluation of the effectiveness
and side effects of her pain medications, and respiratory
treatments, including assistance in using the incentive
spirometer. A chest x-ray was ordered, which revealed
atelectasis in both lower lobes and consolidation on the
left. Antibiotics were started because she had developed
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 Research and Practice: Partners in Care Series

TABLE 2 Tools Used to Assess Delirium4,35,37,38,41/45

Description
Screening tool

Mini-Mental State Examination (MMSE)35
The MMSE was initially created to differentiate organic from functional
psychiatric patients. Used to quantify the severity of cognitive impairment and
to document changes over time. The MMSE can be administered in 5-10 min.
It has seven different categories: orientation to time, orientation to place,
registration of three words, attention and calculation, recall of three words,
language and visual construction.

NEECHAM Confusion Scale (NCS)44 The NCS consists of nine scaled items divided into three subscales: level
of responsiveness, behavior, and vital functions (screening, not diagnostic).
The NCS involves bedside observation and interaction with the patient and
incorporates data from a nurse’s assessment of patient responses.

Delirium Observation Screening Scale (DOS)37 The DOS is designed to assist nurses in the early recognition of delirium
during regular care.

Nursing Delirium Screening Scale (NuDESC)38 The NuDESC is an observational five-item scale that can be completed quickly
and was developed for use in busy inpatient units.

Diagnostic instruments

Confusion Assessment Method (CAM) The CAM and CAM-ICU are diagnostic, observational instruments based on
and CAM-ICU4 the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition.
Intended to provide a standardized method to enable nonpsychiatrically
trained clinicians to identify delirium quickly and accurately in both clinical and
research settings. The CAM-ICU was designed to be used in an environment
when the patient is nonverbal/mechanically ventilated.

Delirium Rating Scale-Revised-98 The DRS-R-98 is the most widely used instrument for rating the severity
(DRS-R-98)41 of delirium over time and consists of 16 items: three are diagnostic of
delirium and 13 are severity-based symptoms found in people with delirium.
The total score is diagnostic of delirium and a severity score indicates
increased delirium symptoms.

Severity of symptom instruments

Memorial Delirium Assessment Scale (MDAS)42 The MDAS is a 10-item scale used to quantify severity of delirium and detect
changes in symptoms. The MDAS assesses arousal, level of consciousness,
cognitive functioning (memory, attention, orientation, disturbances in
thinking), and psychomotor activity.

Bedside Confusion Scale (BCS)43
Delirium Index45
The BCS incorporates a 2-min screening test to observe the level of
consciousness at the time of clinical interaction, followed by a timed
task of attention using recitation of the months of the year backward.
The Delirium Index measures the severity of symptoms of delirium based
on observation of the patient, without additional information from family,
nursing, or the medical chart. It is designed to be used with the MMSE.

a urinary tract infection in addition to pneumonia. Nancy
decided to stay with her mother in her hospital room to
provide a familiar presence because that would help
keep her mother calm and oriented. Nancy also helped
physical therapy mobilize her mother to prevent
functional decline. Nancy also assisted with and insisted
that her mother use the incentive spirometer to expand
her lungs and facilitate optimal oxygen exchange.
With Nancy at her mother’s bedside, food and fluids
were provided continuously, facilitating her mother’s
recovery. Mrs Smith’s husband brought in her hearing
aids and glasses as well as familiar objects from home.
A calendar and clock were placed where she could see
them, and pictures of her grandchildren were put on the
bedside table.
Mrs Smith had a written advance directive for healthcare
and named her husband as durable power of attorney.

Journal of Hospice & Palliative Nursing www.jhpn.com 391

 Research and Practice: Partners in Care Series
Over the last couple of years, both Mr and Mrs Smith
had many conversations about treatment options should
they not be able to make their own decisions. Nancy
and Mr Smith also made it clear to the medical and
nursing staff that Mrs Smiths’ wishes were not aggressive
treatment, but palliative care. Advance directives were
reviewed and orders were clarified to ensure that
Mrs Smith’s wishes were respected and supported.
The palliative care team was consulted and became
involved in Mrs Smith’s care. The family, primary
care provider, nurses, and palliative care team worked
collaboratively with Mrs Smith and her family to
ensure comfort and symptom control without
aggressive treatment.
Nursing Interventions
Delirium is a medical emergency, and the goals of care
are to (1) provide safety for the patient (2) identify the
cause, and (3) treat the cause when possible or appropri-
ate. Treatment focuses on the use of nonpharmacologic
(nursing interventions) and pharmacologic therapy as
needed, and the foundational principle is to treat the un-
derlying cause. In palliative care, treatment of the cause
or causes may not be feasible or possible related to the
disease process, and the goals of care will change as the
disease progresses. However; patient safety, patient
well-being, and patient comfort are the cornerstone of
excellent palliative nursing care.
The first priority for nursing is to maintain a safe, fa-
miliar environment for the patient, whether the setting is
the hospital, hospice, long-term care, or home. Low non-
glare lighting will prevent visual distortions. Surrounding
the patient with familiar objects, such as family photos or
favorite possessions, will provide comfort. Having a
clock and calendar within sight will help the patient stay
in the present. Any object of comfort should be placed
within reach for reassurance. Reorientation to time, place,
and person when and if appropriate is often helpful. Soft,
soothing music may promote a healing environment.
Gentle reorientation and reassurances that you will keep
them safe may help. Glasses and hearing aids must be in
working order and properly placed to maximize commu-
nication. Family members should be allowed to stay with
the patient, especially if the surroundings are unfamiliar,
such as in a hospital, hospice, or palliative care unit. Phys-
ical restraints should never be used because they are a
precipitating risk factor for delirium and can escalate the
behaviors rather than alleviate them. Education and sup-
port are imperative in assisting families through this diffi-
cult time, as they may not understand their loved one’s
behaviors. The bedside nurse is in the ideal situation to
provide much needed comfort and assurance.
Familiar sights, sounds, smells, and touches may per-
haps provide a sense of security and also assist in reliev-
392 www.jhpn.com
ing some distress.46 Aromatherapy may be useful in
reducing anxiety in palliative care patients. For example,
sandalwood oil may be effective in reducing anxiety
when used as massage oil. 47 Gentle massage to the
hands and/or feet may help relieve anxiety and quiet
agitation.
Nurses intuitively know how to provide the best,
evidence-based care for their patients and are therefore
at the forefront of delirium prevention. Nurses are also
vital to the well-being of their patients and derive great
satisfaction when those same patients have improved
and shown progress after an episode of delirium.
Pharmacological Treatment of Delirium
Treatment of delirium is aimed at removing or treating
the underlying cause. The decision to treat with medica-
tion will depend on the patient’s distress or the risk that
the behaviors pose to self or others.48 When using med-
ications in the older adult population, it is imperative to
start low and go slow and the medications are titrated to
effect.48 Haloperidol is most often recommended be-
cause it has fewer anticholinergic side effects, is less se-
dating, has fewer active metabolites, and rarely causes
orthostatic hypotension or cardiovascular side effects.46
Second-line atypical agents for treatment of delirium
are olanzapine, risperidone, and quetiapine.49 Benzodi-
azepines are not recommended for delirium in older
adults because of the risk of rebound confusion, agita-
tion, and risk for falls. These drugs can cause oversedation
and exacerbate confusion.
In addition, haloperidol is contraindicated for patients
with Parkinson disease or Lewy body dementia.
CASE STUDY: PART 3
On her fifth postoperative day, Mrs Smith was walking
with the aid of a front-wheeled walker; she was alert
to her baseline, was eating and drinking without
encouragement, and seemed ready for discharge to
her home with home healthcare. Prior to discharge, a
medical social worker held a family conference to ensure
that the plan of care was clear for Mrs Smith. The
palliative care team collaborated with Mrs Smith and
spent time with her and her family to make certain all
understood the goals of care. Mrs Smith was adamant
that she would not undergo any further diagnostic tests
or aggressive treatments for her heart failure. She wanted
to spend what time she had at home with family and
friends. This was vitally important to her. The palliative
care team assured Mrs Smith and her family that her
wishes would be followed and they were there to
support her. Mrs Smith’s husband and daughter agreed
Volume 14 & Number 6 & August 2012
 Research and Practice: Partners in Care Series
with her wishes as they realized she would not want to
live if she had no quality of life to do the things that
brought her joy.
Summary
Delirium is stressful for both the patient and family
across all settings. The prevalence is highest in vulner-
able populations and particularly for older individuals,
in intensive care units, those who are postoperative,
and those with advanced illness.44 The predisposing risk
factors of advanced age, severity of illness, multiple co-
morbidities, and vision and hearing impairments, as well
as her fall and subsequent surgery to repair her fractured
hip, left Mrs Smith very vulnerable to delirium. The pre-
cipitating risk factors, or the events happening after hos-
pitalization, contributed to Mrs Smith’s delirium, which
included immobilization, dehydration, malnutrition, uri-
nary tract infection, pneumonia, and sleep deprivation.
These predisposing and precipitating risk factors alert
nursing staff that delirium is an acute onset that requires
immediate intervention. Nurses play a key role in the
prevention and recognition of delirium, thus contributing
to optimal outcomes for hospitalized patients. An array
of interventions that range from safety to comfort must
be considered for the patient experiencing delirium, re-
gardless of setting. Palliative care teams can provide sup-
port and assistance in symptom control, pain management,
and family support. The patient and family goals for pallia-
tive care are a difficult balancing act for all involved but,
when done well, bring comfort to those for whom we care.
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