150 PART THREE | DELIRIUM study to examine pharmacological management of delirium symptoms in patients with advanced cancer [86]. This study demonstrated no benefit with risperidone or haloperidol in the relief of distressing target symptoms of delirium; in fact, these symptoms were worse with both of the antipsychotics than with placebo. Remarkably, no patients in this study had severe delirium, which limits the generalizability of study findings in relation to the severe episodes of delirium that can occur in cancer patients, especially in the context of advanced disease. Therefore, the use of pharmacological interventions in the management of delirium in adults should be limited to patients who have distressing delirium symptoms (such as perceptual disturbances) or if there are safety concerns where the patient is a potential risk to themselves or others. Further trials of antipsychotics in severe delirium, including subgroup analyses in relation to different precipitating factors, phenomenology and symptom expression, are required to confirm this. These studies should include a comparator placebo arm. In the absence of a placebo arm, improvements in delirium noted in a cohort study may be explained by a response to treatment of the precipitants of the delirium episode rather than a response to the antipsychotic drug. The failure of pharmacological treatment studies may be related to the heterogeneous nature of delirium. Therefore, unravelling distinct mechanistic routes that lead to delirium should remain an important priority. Another priority is the design and testing of multidomain delirium treatment processes in oncology settings. This multidomain approach can be summarized as follows: addressing the often multiple delirium triggers, correcting physiological disturbances, treating the symptoms of delirium including distress, communicating with patient and carers, and addressing the current and future risks linked with delirium. Addressing each of these domains requires highly skilled systematic care from a multidisciplinary team. Given the lack of studies and the lack of definitive evidence of the effectiveness of multidomain treatment, recommendations regarding general delirium treatment are still based on expert consensus rather than on trial evidence. In conclusion, the overall goal of supportive and palliative care is to improve the patient’s quality of life congruent with the patient’s preferences- ie, the patient- centered perspective. Improvement of function and optimal symptom management throughout the disease trajectory are key elements of both supportive and palliative care. This Improvement can be achieved by early integration of oncology and supportive / palliative care guided by the patient’s needs. For supportive and palliative care, as with other disciplines, the development of evidence-based practice requires access to good quality and relevant evidence. Prospective, well-designed and preferably, intervention studies are needed to evaluate the impact of palliative and supportive interventions on outcomes and QoL in patients with advanced cancer. Despite a growing awareness of the need to develop supportive and palliative care and recent progress in the field, more scientific evidence, tailored to individual and fluctuating patient needs, is required so that effective interventions can be recommended to cancer patients at each stage of their illness.
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