Commentary

Naomi has advanced cancer, but her sudden change still needs assessment. Consider high calcium levels, dehydration, constipation and medicine effects in relation to her care goals and the burdens of treatment. Offer proportionate treatment for possible causes while addressing fear and discomfort. Agitation or a cancer diagnosis alone is not a reason to label delirium terminal.

Naomi becomes comfortable enough for a short conversation with Joel, but her attention remains inconsistent. The conversation is valuable to them without establishing that she has recovered from delirium. Palliative care reports describe goals such as contact with family or relief of specific symptoms [S10, S14, S15]. They do not establish that every person will respond to treatment in the same way.

When Naomi deteriorates later, staff reassess her progressive illness, previous wishes and course so far. They decide to focus on comfort after this review, rather than because delirium has lasted a set number of days. Monitor medicines for severe symptoms for both intended benefits and burdens. Reduced activity alone does not establish that distress has been relieved [T01].

Naomi dies with Joel present. She does not fully recover from delirium. Care, communication and attention to suffering continue throughout her illness. Keep reviewing which treatments are proportionate and how to recognise distress as she communicates less. Explain uncertainty to relatives without promising recovery or assuming that rapid deterioration is inevitable.