Reflections on the “Ban Haldol?” Poll So Far

Well, it’s been a little over a month since I posted the poll asking readers whether or not they’d ban the antipsychotic haloperidol for managing agitation in delirious patients hospitalized on intensive care units (ICUs). And most of the time, a majority of voters would choose not to ban the antipsychotic. See the original post for a review of the background, Ban Haldol? – The Practical Psychosomaticist.

It was a tough question. I’m not so sure what this shows, except I prefer to believe most of us would get rid of haloperidol altogether if we could truly prevent delirium. This is really a question to get us thinking about preventing delirium, not just in the ICU, but everywhere it occurs, including on pediatric units and nursing homes.

The poll was unfair, I admit. I’m a bit surprised at the stability of the outcome so far, but I doubt it has much to do with the perceived adverse effect profile or efficacy of the drug. I’ve been called to the ICU and other units in the general hospital for many years to help physicians and nurses manage delirium.

“Manage delirium” is almost a contradiction in terms. Anyone who has seen a family member suffer from delirium or directly experienced this acute episode of confusion caused by medical problems probably has the sense that, once delirium gets started, there’s not much doctors can do about it. This is especially true of the elderly and those with pre-existing cognitive impairment. The underlying medical conditions can be treated and even shown to reverse. But often that doesn’t result in a corresponding resolution of the delirium itself.

There are several scenarios in which I have recommended against using any psychotropic drug, especially antipsychotics. One of them is in the setting of prolonged cardiac conduction. Antipsychotics (and many antidepressants unfortunately) can themselves cause the QTc (corrected QT) interval to lengthen, putting a patient at risk for suffering potentially life-threatening arrhythmias. This would be on top of any intrinsic risk arising from pre-existing heart disease.

Moreover, some patients won’t tolerate other side effects of antipsychotics, which can include painful dystonic reactions and extreme restlessness.

The poll really makes me think about the need for more research into the basic pathologic mechanisms underlying delirium, which could lead to methods which help us identify those with specific risk factors. About the best we’ve got so far is that we know if you’re older than 65 and already have cognitive impairment, you’re more likely to get delirious.

The research into delirium prevention protocols absolutely needs to continue and also needs to be top-notch in quality.

We hate to see our patients and family members suffer from terrifying hallucinations and delusions, severe agitation which threatens their safety, and the gross cognitive disorganization that makes them forget the names of the loved ones who watch this scenario play out in hospitals all over the world.

That’s why it’s so important for to support organizations dedicated to the study and prevention of delirium, including but not limited to:

American Delirium Society

European Delirium Association |

Academy of Psychosomatic Medicine — Home Page

I think the poll results don’t mean we like haloperidol.  I think the poll reflects our awareness of the kind of suffering delirium causes.

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