From the Guidelines
For a patient under hospice care who requires frequent lift assistance and becomes aggressive during transfers, I strongly recommend contacting the hospice care team immediately to request a care plan reassessment, focusing on alternative transfer methods and behavioral support, as suggested by the most recent expert recommendations 1. The patient's situation is complex, involving both physical and behavioral challenges that need to be addressed to ensure safety and quality of life. Given the decline of the Hoyer lift due to safety concerns, alternative transfer devices such as a slide board, transfer belt, or mechanical sit-to-stand lift could be considered to facilitate safer transfers. Key considerations include:
- Evaluating the patient's environment to identify potential fall hazards and implementing modifications to enhance safety, such as removing tripping hazards or installing handrails.
- Reviewing the patient's medication regimen to ensure that it is optimized for managing pain, discomfort, and agitation, which could be contributing to the aggressive behavior during transfers.
- Utilizing mobility assistance devices as part of a broader strategy to manage frailty and enhance the patient's ability to move safely, as recommended in recent expert guidelines 1.
- Implementing cognitive interventions and behavioral strategies to address the patient's confusion, fear, or pain that may be triggering aggressive behavior during transfers. The hospice social worker should be involved to explore additional community resources and respite care options that can provide relief to the caregiver and support the patient's needs. This comprehensive approach prioritizes the patient's safety, comfort, and quality of life, while also addressing the caregiver's burden and need for support.
From the Research
Patient Care and Mobility Assistance
- The patient's situation involves requiring lift assistance due to the wife's inability to move him, and hospice has declined the use of a Hoyer lift due to safety concerns for both the patient and his wife 2.
- The patient's aggressive behavior when not understanding or being moved suggests the need for careful management of delirium symptoms, which can be challenging in palliative care settings 3, 4, 5.
- Studies have shown that the use of antipsychotics like haloperidol and risperidone may not be effective in reducing delirium symptoms and can even increase the risk of adverse effects like extrapyramidal symptoms 3, 5.
Mobility Assistive Devices
- The use of mobility assistive devices such as canes, walkers, and wheelchairs can be beneficial for patients with mobility issues, but proper sizing and patient education are essential to avoid skin breakdown and ensure safe use 6.
- In this case, the patient's need for lift assistance and the wife's inability to provide it suggests that a mobility assistive device may not be sufficient to address the patient's needs.
Management of Delirium Symptoms
- The use of lorazepam in combination with haloperidol has been shown to be effective in reducing agitation in patients with delirium, but further research is needed to assess its generalizability and adverse effects 4.
- Individualized management of delirium precipitants and supportive strategies have been shown to be effective in reducing distressing delirium symptoms, and may be a better approach than the use of antipsychotics like risperidone or haloperidol 5.