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

Delirium is a common condition at the end of life and causes significant distress in patients and their loved ones. A precipitant factor can be found in less than half of the patients and the management interventions are limited.

A patient in his late sixties with low English proficiency with a metastatic neuroendocrine tumor was transferred to a palliative care unit on non-invasive bilevel ventilation. He appeared to become delirious and agitated, trying to remove the face mask, wriggling in bed, and tapping the bedrails. Haloperidol and lorazepam were required when non pharmacological interventions failed to calm him down. The following morning, the patient was able to explain that the positive-pressure facemask was suffocating him and that he could not breathe. So, he was transitioned to high-flow oxygen via nasal cannula, and within a few hours, his respiratory distress significantly improved, and he regained his previous self.

In this report, we highlight the challenges faced by clinical teams diagnosing and managing delirium, in particular when a language barrier is present. Non-invasive bilevel ventilation is generally avoided in patients at the end of life (unless it offers comfort and it is aligned with the patient's wishes), but if used should be considered as a cause of agitation and worsening shortness of breath, especially when it can be easily tested by removing the facemask.