Advance Directives, QoL-Focused Care Needed for Cancer Patients With Delirium in the ED

08/03/17

Patients with advanced cancer who visit the emergency department (ED) with delirium have increased rates of hospitalizations and ICU admissions, along with decreased survival rates, according to a recent study published in The Oncologist (online August 1, 2017; doi:10.1634/theoncologist.2017-0115).

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Delirium is the most common and serious neuropsychiatric complication in patients with advanced cancer; it can be seen in 25% to 85% of hospitalized patients with cancer. Early diagnosis in the ED should improve management, but delirium is frequently underdiagnosed by ED clinicians, and outcomes data is limited.

Ahmed F Elsayem, MD, associate professor, department of emergency medicine, University of Texas MD Anderson Cancer Center, and colleagues conducted a study to improve the management of advanced cancer patients with delirium in an ED setting. Researchers randomly compared and assessed 243 patients with advanced cancer for delirium using the Confusion Assessment Method (CAM) and the Memorial Delirium Assessment Scale (MDAS) and for presence of advance directives. Patients were grouped based on diagnosis from both the CAM and MDAS (group A, n = 22); the MDAS alone (group B, n = 22); and neither CAM nor MDAS (group C, n = 199).

Outcomes recorded from patients’ medical records included hospital and ICU admission rates and overall survival (OS).

Hospitalization rates among groups A, B, and C were 82%, 77% and 49%, while ICU rates were 18%, 14%, and 2%, respectively. Advance directives for the three groups were 52%, 27%, and 43%, respectively. Median OS was 1.23 months (95% CI, 0.46–3.55) for group A, 4.70 months (95% CI, 0.89–7.85) for group B, and 10.45 months (95% CI, 7.46–14.82) for group C.

Researchers noted that OS did not differ significantly between groups A and B (P = .6392), but OS in group C was higher compared with the other groups (P < .0001 each).

Authors of the study concluded that delirium diagnosed by either CAM or MDAS is associated with worse survival outcomes and more hospitalizations in patients with advanced cancer in an ED setting. Furthermore, a majority of patients with advanced cancer with delirium in ED lack advance directives.

“Clinicians caring for advanced cancer patients with delirium in EDs should strongly consider focusing on goals of care, resuscitation preferences, and quality of life for patients and their family members,” said Dr Elsayem in a press release (August 1, 2017).—Zachary Bessette