Not everything is delirium at the end of life: a case report

VSports - Introduction

Delirium at the end of life, a frequent, grueling diagnosis in palliative care medicine, is reported to occur in up to 85% of patients (1) V体育官网. Characterized by acute fluctuating confusion, disturbance of attention, and altered consciousness with plus/minus agitation, delirium is associated with worse survival and causes significant distress not only in the patient but also in their loved ones and caregivers (2,3). Thus, to ease the suffering of the patient, family members put pressure on nurses and medical personnel to increase sedation and/or analgesics, which could lead to an unwarranted dose increase of opioids, sedatives, and/or antipsychotics, increasing the risk for toxicity (4).

The most important steps in managing delirium in the palliative care setting are to determine the etiology, whether it is reversible, and whether the potential treatment is feasible, in particular considering that the evidence supporting non-pharmacological and pharmacological interventions is limited (3). All these components of the diagnosis and management of delirium can be further complicated when a language barrier is present between the patient and the clinical team. A language barrier can result in worse health care quality, outcomes, and overall satisfaction in general and in particular, in palliative care because treatments are guided by the presence and intensity of the symptoms, such as pain and anxiety. As an example, a systematic review found that patients and families with low English proficiency receiving palliative care services experienced poorer symptom management—when professional interpreters were not used—because of the lack of full understanding regarding the diagnosis and prognosis during goals of care conversations (5). Here, we report a case of misdiagnosed delirium in a patient with limited English proficiency, receiving end-of-life care for advanced metastatic disease. We present this case in accordance with the CARE reporting checklist (available at https://apm. amegroups. com/article/view/10 VSports手机版. 21037/apm-25-37/rc).

"V体育ios版" Case presentation

A Pacific Islander patient in his late sixties who spoke only his native language presented to a university cancer center after being diagnosed with an advanced neuroendocrine metastatic cancer V体育安卓版. Two months before his admission, a workup for weight loss revealed the malignancy; a local oncologist relayed a very poor prognosis and offered to pursue non-curative palliative treatment along with hospice care. The distraught family opted to sell their home and land, choosing to travel to Texas for a second opinion.

After arriving at the hospital directly from the airport, the patient was found to be deconditioned and cachectic with a very poor performance status. His body mass index (BMI) was 14. 7 kg/m2, and he required assistance for the activities of daily living V体育ios版.

The patient and family expressed that they were willing to exhaust all avenues in obtaining any treatments, despite knowing that the goal was not curative. After the first treatment with chemotherapy, the patient developed acute kidney injury and acute respiratory distress requiring non-invasive bilevel ventilation. Imaging revealed worsening of pulmonary metastases. In view of the further decline, he was deemed ineligible for additional treatments, a decision was made to avoid escalation of care, and goals of care discussions were initiated. There were very few translators of his language, and they were frequently unavailable. Usually, the wife acted as a translator VSports最新版本.

The patient was then transferred to the Palliative and Supportive Care Unit, on non-invasive bilevel ventilation and was started on a continuous infusion of fentanyl for air hunger and bone pain. During his first evening, he became grossly agitated, trying to remove the face mask of the non-invasive ventilation, wriggling in bed, and tapping on his bedrails. The nursing staff were unable to redirect the patient and were challenged by the language barrier, along with the patient’s wife, who was also unable to understand her husband. She became severely distraught, leaving the room and screaming for help in the hallways. The patient was treated with intravenous haloperidol without any improvement, so lorazepam was given. Finally, the patient calmed down and fell asleep.

Upon waking up in the morning, the patient was able to explain to his wife that the positive-pressure facemask was suffocating him and that he could not breathe. Once the team learned that the cause of his behavior was the facemask, it was immediately removed and transitioned to high-flow oxygen via nasal cannula. After the change and within a few hours, his respiratory distress significantly improved, he was smiling, watching videos on his cell phone and was even able to speak an elementary English, which facilitated the communication. He also reassured the team that he was pain-free and fully oriented.

Throughout the following days, the fentanyl infusion was rotated to methadone and oxycodone for breakthrough pain. His high flow nasal cannula (HFNC) was further weaned and changed to a regular nasal canula, which allowed him to fly back home five days later.

All procedures performed in this study were in accordance with the ethical standards of the institutional and/or national research committee(s) and with the Declaration of Helsinki and its subsequent amendments. Publication of this case report was waived from patient consent according to the Institutional Review Board of the University of Texas MD Anderson Cancer Center.

"VSports" Discussion

This case highlights the difficulties elucidating the etiology of agitation in a patient on non-invasive ventilation receiving end-of-life care, in particular when a language barrier is present.

Intolerance to non-invasive ventilation is a complex topic, but can be summarized as caused by the interface (facemask), the anchoring system of the mask (the strap), the ventilator settings (especially when there is a mismatch between the patient’s own breathing and the mechanical action of the ventilator), the humidification, and the noise (6). Any of these elements can worsen the patient’s shortness of breath or discomfort, leading to anxiety and agitation (6). To avoid some of these problems, HFNC has become the standard first-line treatment for acute hypoxemic respiratory failure because it is not associated with facemask issues, muffled communication, claustrophobia, and inability to eat (7). But regardless of the modality, it is important to emphasize that the primary purpose of using non-invasive ventilation in patients undergoing palliative care should not be to correct the saturation but to alleviate the shortness of breath (7), and that very few palliative care patients can be weaned from HFNC creating significant issues about disposition, inability to discharge the patient, and forcing families with the decision of discontinuation (7). Fortunately, our patient could be weaned from the bilevel ventilation to HFNC, and then to a regular nasal cannula.

Unfortunately, our patient’s agitation was misdiagnosed as delirium and treated with haloperidol and benzodiazepines after non-pharmacological interventions failed to improve his condition. Since delirium is reversible in only 25–68% of cases, it is critical to try to determine the causes and, if feasible, address them, but a treatable etiology can only be found in less than half of the patients at the end of life (3). The following issues should be taken into account when managing these patients: the safety of the patient and those around them; the best place to provide care; information and education for the patient and their family; addressing underlying causes if possible; minimizing offenders who may exacerbate symptoms such as pain, constipation, urinary retention; preventing dehydration; identifying mediators of distress; taking into account the patient’s priorities; realizing that delirium may be experienced as a sense of losing a loved one; and awareness of the patient’s poor prognosis (3). Not infrequently, family members and staff misinterpret agitation as discomfort and pain, and the psychological trauma experienced by families during an episode of agitation can cause a profound misperception of the problem [known as the “destructive triangle” (8)], in which the patient, the families, and the caregivers become more and more distressed (3). This is exactly what happened in our case and the wife of our patient became increasingly distressed, particularly when she was not able to understand her husband because of the facemask of the non-invasive bilevel ventilation. Attempting to get help, she became desperate and began to shout for help in the hallways. Once the patient became calm after sedation, she regained her composure and was cooperative with the clinical team.

An important barrier to the care of this patient was his low English proficiency. Certainly, this contributed to the misdiagnosis of delirium when the worsening distress was caused by the non-invasive ventilation. A high index of suspicion is required, and we missed something as simple as removing the mask, even temporarily, to check if his breathing would improve without it. But there is another aspect that needs to be considered regarding the language. Healthcare facilities that receive federal funding are required by Title VI of the Civil Rights Act to provide free interpretation services to patients and their families, regardless of insurance status (9), however given the very unusual language required in our patient (we have not mentioned it to preserve the privacy of the case), the wife was the only “de facto” translator available, which probably added an enormous burden of stress on her. To analyze the extra challenges of translating her husband, we can look at studies investigating professional interpreters. In semi-structured video interviews about experiences of interpreters during palliative care encounters, they exposed the lack of verbatim translation of “palliative care” in many languages, and described that patients with low English proficiency seemed to have poor understanding of their prognosis, treatment goals, and the role of the palliative care team (10). And when looking to the emotional toll, interpreters translating for palliative care patients had a wide spectrum of responses, including sadness/upset, distress, feeling overwhelmed, deep emotional distress, guilt of conveying bad news, and loneliness (11). Therefore, part of the wife’s anger and distress could be explained not only by the anxiety caused by her husband’s disease but also but the challenges facing her as a translator.

Conclusions

We presented the case of a patient with metastatic cancer undergoing palliative care, not fluent in English, who was misdiagnosed as having delirium when he was struggling to breathe with non-invasive bilevel ventilation. Agitation, caused by non-invasive bilevel ventilation, needs to be considered as a differential diagnosis, realizing that it can be easily tested by removing the facemask. We also highlighted the challenges faced by family members, acting as translators of the health care team, which is a practice that ought to be avoided, especially when dealing with an end-of-life situation of a loved one.

Acknowledgments

None.

Footnote

Reporting Checklist: The authors have completed the CARE reporting checklist. Available at https://apm.amegroups.com/article/view/10.21037/apm-25-37/rc

Peer Review File: Available at https://apm.amegroups.com/article/view/10.21037/apm-25-37/prf

Funding: None.

Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://apm.amegroups.com/article/view/10.21037/apm-25-37/coif). E.B. serves as an unpaid editorial board member of Annals of Palliative Medicine from February 2025 to January 2027. The other authors have no conflicts of interest to declare.

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. All procedures performed in this study were in accordance with the ethical standards of the institutional and/or national research committee(s) and with the Declaration of Helsinki and its subsequent amendments. Publication of this case report was waived from patient consent according to the Institutional Review Board of the University of Texas MD Anderson Cancer Center.

Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.

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