CLINICIAN’S CORNER PERSPECTIVES ON CARE AT THE CLOSE OF LIFE Agitation and Delirium at the End of Life

Mr L was a 59-year-old man with metastatic non–small cell lung cancer. He was brought to the hospital for progressive lower extremity weakness and gait instability that had developed over several weeks and worsened in the preceding 2 or 3 days. His partner, Ms P, was having difficulty caring for him at home because Mr L continually fell when attempting to get out of bed on his own. She found this extremely frustrating and was concerned about his safety. Mr L’s cancer had been diagnosed 3 years earlier and treated aggressively with multiple chemotherapy regimens and radiation therapy. Two years ago, Mr L developed brain metastases and underwent 3 gamma-knife radiation treatments. One month previously, his oncologist discussed the possibility of additional chemotherapy, but Mr L decided to pursue comfort measures only. He was referred for home hospice for management of pain and debilitating fatigue. During the following month, his neurological status deteriorated and Ms P noted changes in his personality. She brought Mr L to the emergency department, where he was irritable, uncooperative, and verbally abusive to the staff. Computed tomography and magnetic resonance imaging scans of the brain revealed new mild depression of the cerebellar tonsils, suggesting an increasing mass effect from his brain metastases, and worsening ventriculomegaly, but no new brain lesions. Mr L was treated with lorazepam to control his irritability and verbally abusive behavior. However, after the lorazepam was administered, he became more agitated and restless and fell while attempting to get out of bed. The staff placed him in wrist restraints to control his behavior and admitted him. On hospital day 2, after a palliative care consultation, he was transferred to a comfort care suite. The restraints were removed, and a 24-hour sitter was engaged to ensure his safety. His agitation was believed to be due in part to uncontrolled pain, so morphine was initiated and titrated to