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Before the next difficult encounter

Example case

Your first task is to recognise the danger and obtain help while keeping communication calm. The team also needs to assess the new change and treat possible causes. Repeated explanation alone may be insufficient.

Complete Delirium in 30 first

This course builds on the foundation module. It assumes you understand acute change, fluctuation, hypoactive delirium, assessment and the need to look for causes. A person with delirium may misinterpret care as a threat. Agitation describes increased restless activity; aggression involves threatening or harmful behaviour. Either needs careful assessment. Some severely distressed people remain still or say very little.

By the end, you should be able to choose a safer first response, use words that support engagement, recognise when to withdraw and call for help, and explain the limited place of medication. You will also practise a care handover.

This is education for adult health and care staff worldwide, including staff working in intensive care. Apply your own emergency routes, law and policies. Practical restraint, emergency medication and specialist ICU assessment require separate local training and competence.

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Immediate danger or an opportunity to pause

Look at what is happening before approaching. Has the person become difficult to wake? Are they struggling to breathe, collapsing, having a seizure or rapidly deteriorating? Is anyone at immediate risk of serious injury?

A delirium score should never delay emergency treatment. A fall, low oxygen, low blood glucose, stroke, seizure, infection, pain or another acute problem may require immediate assessment. Check or treat these only within your training and role.

When there is time to slow down

Pause non-urgent care that appears to be increasing distress. Reduce the number of people speaking and the noise around the person. Ask one staff member to lead the conversation while another arranges help and observes safety. Explain what you intend to do before approaching or touching.

If the situation becomes unsafe, withdraw to a safer position and call for help. Do not remain within reach to complete a conversation. Keep observation from a safe place where possible. Family members should never be asked to hold or physically control the person.

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Therapeutic engagement

Therapeutic engagement means using your attention, words and actions to understand the person’s experience and help them receive care. It begins before an episode of severe agitation.

Introduce yourself and use the person’s preferred name. Approach where they can see you, allow personal space and adopt a non-threatening posture. Adjust your eye contact to the person’s preferences and culture. Check hearing, vision and language needs. Use an interpreter when needed.

Use one short idea at a time and allow a pause for the answer. Repeat information without turning orientation into a quiz. Explain procedures before starting. Touch may reassure one person and frighten another: ask and observe their response.

After the video: What might you learn by spending a short period with the person before a procedure? Consider what they believe is happening, whether they are in pain and what helps them feel more secure.

Offer family involvement if the person welcomes it and the family wishes to help. Ask what usually reassures them. A familiar person may help, but the response varies. Responsibility for care and observation remains with the service.

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Words and actions during de-escalation

De-escalation aims to reduce distress and the risk of harm through communication and changes to the situation. It is an ongoing response to the person, rather than a script that always works.

Listen for the reason behind an action. Someone pulling away may be in pain, need the toilet, be unable to hear you or believe that you intend to hurt them. Treat the concern as information that needs attention.

Acknowledge the feeling without confirming a false belief. Avoid argument, repeated challenges, threats or promises you may be unable to keep. Offer a small number of choices that are safe and achievable. If the person reports harm or mistreatment, listen and assess it through the appropriate safeguarding process. Delirium does not establish that a report is untrue.

Consent and decisions

Delirium does not by itself establish that someone lacks capacity to make a decision. Support communication and seek an appropriate assessment of the specific decision at that time. Capacity means the ability to make that decision with the support available, under the applicable legal test. Refusal or an unwise choice alone does not establish incapacity. If a decision can safely wait, consider a time when the person is better able to engage. Urgent care and any restriction must follow the applicable law and local procedure. Family support and legal authority to decide are distinct.

Discuss the scene: What might the person be experiencing? Before offering touch, consider personal space, whether it is welcome and whether it is safe. The clip illustrates distress; it is not a demonstration of managing violence.

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Patient safety beyond agitation

Plan for the person’s current abilities. Risk may change over hours, and a calm appearance does not establish safety or comfort.

• Falls and leaving the care area: assess mobility, toileting needs, supervision and the environment. Offer assistance and purposeful activity. Use an individual plan and the least restrictive safe approach. Bed rails may introduce climbing or entrapment risks and need their own assessment.
• Eating, drinking and medicines: check alertness, positioning and the swallowing plan. Do not give food, drink or oral medicines while swallowing is unsafe. Obtain prompt clinical advice and a plan for fluids, nutrition and essential medicines. Coughing during meals or a wet, gurgling voice needs prompt clinical review. If choking makes breathing difficult or the person is unable to cough effectively, summon emergency help and start the choking response within your training.
• Lines, tubes and oxygen: explain their purpose. Ask the clinical team which devices remain necessary and whether a safer, less intrusive option is suitable. Essential treatment changes require the responsible clinician.
• Reduced movement: follow the mobility and pressure care plan. Check comfort, hydration, nutrition and access to sensory aids.

After the video: Encouragement alone does not establish that eating is safe. Check alertness and the individual swallowing plan before continuing. A new reduction in engagement also needs reporting and assessment.

Close observation should include engagement and practical help. If the agreed observation or staffing is unavailable, escalate the unmet need and make an interim safety plan with the senior team. A relative’s presence is optional and does not replace appropriate staffing.

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Staff safety and a coordinated response

Staff should be able to give care without accepting avoidable injury. Understanding that illness may contribute to aggression should improve the response and the support offered to everyone involved.

Know how to summon help before a difficult encounter. Keep personal space and access to an exit. Avoid crowding, cornering or approaching unexpectedly from behind. Follow local lone-working arrangements. In community care, move to safety and call the local emergency service if serious danger develops.

Roles during an incident

Agree who leads communication, who coordinates the clinical response and who calls additional help. Move bystanders away when safe. Trained security staff may assist with immediate safety; the clinical team remains responsible for assessment and treatment.

Do not attempt a hold or restraint technique from this course. Physical restraint is an exceptional response to imminent injury when a less restrictive response is insufficient. It requires trained staff, the appropriate legal authority, monitoring and repeated review. Continue attempts to reduce distress where safe. Use the least restrictive effective response for the shortest necessary time. Never use restriction as punishment or for staff convenience.

Record observed actions and injuries using specific language. “Hit a staff member when the catheter was touched” is more informative than a label about the person’s character. Arrange medical care and support for injured or distressed staff and others.

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Medication when a clear need remains

Treatment of pain and other causes continues throughout. A medicine directed at severe delirium-related distress or agitation may be considered when there is significant distress or risk of physical harm, after contributing factors have been assessed and addressed as far as possible and attempts to reduce distress have failed. An emergency may make those approaches inappropriate. An authorised prescriber should make and document the decision under the applicable guidance.

The aim is a defined clinical benefit, such as relief of severe distress or preventing serious injury. Routine sedation for convenience is inappropriate. Antipsychotics, a group of medicines sometimes used for severe distress or agitation, are not recommended simply to prevent delirium or speed its resolution.

Before and after giving a medicine

The prescriber chooses the medicine and sets the review plan. Staff who administer it complete the required checks and monitoring. All staff should report a concerning change promptly within their role.

Establish the target symptom, what has already been tried and the intended benefit. Review current medicines, interactions, previous reactions, heart rhythm risk, Parkinson’s disease and dementia with Lewy bodies. Discuss the decision with the person as far as possible and involve the appropriate supporter or legally authorised representative under local law.

Use the lowest clinically appropriate dose for the shortest necessary time, with a clear review and stopping plan. Monitor the response and adverse effects according to the medicine, route and local protocol. Excessive sleepiness, breathing problems or deterioration require urgent clinical assessment. A person becoming still after medication does not prove that distress or the underlying illness has improved.

Haloperidol must not be used in Parkinson’s disease or dementia with Lewy bodies. Other antipsychotics also need specialist judgement in these conditions. Benzodiazepines, sedative medicines, are generally avoided for delirium unless there is a specific indication, such as alcohol or benzodiazepine withdrawal. Seek the relevant specialist pathway.

National guidance differs in the circumstances and medicines recommended. This course does not give drug doses or a rapid tranquillisation regimen. Prescribers should use current local guidance and the linked specialist sources.

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Intensive care

Threats to the airway or essential devices need immediate help. If you work in ICU, call the appropriate bedside nurse, senior clinician or emergency team under your unit’s procedure. Other staff should alert the bedside ICU team immediately. Assessment should include pain, breathing, oxygenation, delirium, medicine effects or withdrawal, and difficulties communicating. Agitation during a change in sedation does not establish delirium by itself. Do not assume restraint will prevent tube removal. The ICU team must assess alternatives and the risks of restraint, including increased agitation.

Use one speaker and short explanations. Establish a workable communication method, such as agreed yes/no responses or a communication board suited to the person’s abilities. Check glasses and hearing aids, and involve a familiar person if appropriate. Explain procedures even when the person responds very little.

ICU teams assess pain, arousal and delirium as related but distinct problems. RASS measures agitation and sedation. CAM-ICU and ICDSC are delirium assessment tools used according to their own requirements. Deep unresponsiveness can prevent a valid delirium assessment. Do not convert RASS into a 4AT score.

Use the unit’s current approach to sedation, breathing trials, delirium assessment, mobility, sleep and family involvement. Eligibility and contraindications need individual assessment.

The 2025 SCCM PADIS focused update supplements the 2018 guidance. It found insufficient evidence to recommend for or against antipsychotics for treating ICU delirium. Sedation choices and emergency drug regimens belong to the ICU team and its current protocols. See also the ICU Liberation resources.

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After the immediate danger has passed

Reassess the person’s physical condition, attention, comfort and remaining risks. Check for injury and adverse effects of medication or restriction. Review causes and the continuing need for devices, observation and treatment.

Explain what happened when the person is able to engage. Listen to their account without assuming that all memories are inaccurate. Offer family information and a chance to ask questions. Avoid blame or asking the person to apologise for symptoms of illness.

Support staff and other people affected. Arrange incident reporting and a proportionate review under local policy. Discuss what preceded the episode, which responses helped or worsened it, and what the team will change. Do not judge success only by whether movement or noise stopped.

A useful handover

Include the new symptoms and likely causes, the person’s fears or preferences, specific safety concerns, what helped, what increased distress, medicine effects and the plan for observation and review. Record who will review the person and when.

Before transfer or discharge, review medicines started for the episode and document the stopping plan. Ongoing delirium or distress needs continuing care and appropriate follow-up.

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Apply this to your workplace

Return to Mr Okafor. The team creates space, calls help and explains each action. His daughter says he believes the oxygen tubing is restraining him. Clinical assessment identifies pain and low oxygen. The team treats these, reviews the device arrangement and agrees how to approach future care. His response still needs monitoring.

Practise a short handover, aloud on your own or with a colleague: what has changed, what is unsafe, what the person may be experiencing and what help you need. Use only the information available. Identify any details that need confirmation. For example: “Mr Okafor has become frightened and is trying to stand. He is pushing staff away when they approach his oxygen. We have created space and need clinical assessment and help with safety now.”

After the course, use the local teaching guide to establish:

• How to call clinical emergency assistance and help with threatened violence.
• Who can review persistent distress, medicines and decisions about restrictive interventions.
• How to obtain interpretation, communication aids and additional observation.
• How staff and patients receive support after an incident.

For educators: allow additional time for rehearsal using your local policies. Completion of this module records learning from the course. Demonstration of clinical skills requires supervised practice and local assessment.

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Assessment and feedback

Answer all ten questions, then read the explanation for each answer. You can revise your answers and try again. A completion certificate becomes available after you meet the course criterion and confirm that you have reviewed the feedback.

The criterion is at least 8 out of 10, including all five safety questions: immediate danger, staff withdrawal, swallowing, haloperidol and the response after medication.