Management challenges at end-of-life in a patient with agitated delirium and benzodiazepine withdrawal at comprehensive cancer care center

Most people have some idea of how they want to live their life; however, an estimated two-thirds of Americans have not completed their advance directives. This becomes an issue when up to 90% of patients develop delirium during their final days of life, at which point we depend on advance directives or surrogate decision-makers. Here, we present a case of terminal delirium in a patient with advanced cancer and a history of alprazolam abuse who had not discussed his end-of-life wishes with the medical team or with his estranged family. Treatment was provided to address reversible causes of delirium, including correcting electrolyte imbalances, urinary retention, and administered antibiotics for purulent otitis media. Hyperactive delirium was managed aggressively with intravenous neuroleptics and benzodiazepine, while keeping a balance between somnolence and control of agitative symptoms. Without knowing the patient’s wishes, the family continued to struggle with decision making. However, with multidisciplinary team approach patients and caregivers’ symptoms were better managed. Family then requested us to transfer him to a local hospice facility. The patient eventually passed away peacefully surrounded by his family members. This case highlights the importance of advance care planning, addressing emotional distress in estranged family members regarding symptom burden, and developing the appropriate treatment regimen for a delirious patient with a history of benzodiazepine abuse. Our case serves as a reminder of the support, guidance, and impact that inpatient palliative care teams can offer to both the patient and caregivers.