They’re often called in the literature ‘unreal’ memories. Basically though they’re real for the patient. That is what the patient is experiencing, that is their reality.
We go and visit people on the wards when they can talk about their experiences; then we try to go out within a few days of discharge initially, and we’ll go round every week to every couple of weeks to see people. And that helps, because it helps to normalise the fact that a lot of people have hallucinations. A lot of people don’t want to talk about them, because they’re worried that …they’ve become mentally ill.
I can remember going to see one patient on the ward with a student nurse, and we’d looked after the patient on the unit, and he couldn’t remember who either of us were. And he said ‘I was seeing this, I was seeing that’, and she was so struck by what he was saying – she said ‘but he didn’t seem to be seeing any of those things’. He didn’t seem to be, but he was. Sometimes you can see if a patient is [hallucinating] – they might be brushing something off them, or picking at something, but a lot of the time it’s going on internally, as opposed to there being any sort of physical demonstration.
A ‘delirium’ is a disturbance in your consciousness and your awareness of what’s around you, and obviously you can’t concentrate if you’re delirious. But if you’re hallucinating, you might be able to concentrate but you’re …focussing on other things. We do CAM ICU scoring, which is the confusion assessment method – to find out if there’s any change from baseline mental status, or if there’s an acute change, if the patient is able to focus and has an attention span, which is obviously one of the predictors of delirium, loss of attention. But that doesn’t actually test hallucinations.
We have some patients who have been hallucinating but not delirious. They would say ‘no, I’m fine, I can squeeze your hand, I can answer all of these questions, but why is that mouse running across the floor over there?’ I’ve had quite normal conversations with people and they’ve said ‘oh, and tell my brother to go and get a cup of tea’, and you have to say ‘your brother isn’t here’. There’s no formal [assessment] tool, so what we do is we try to encourage people, to ask ‘What are you seeing? Are you seeing anything unusual?’
I think we certainly see some more commonly than we see others. Being at sea, that’s fairly common – I’m assuming because people are on those moving beds very often – the biowave mattresses – and if you’re a bit thirsty or you’ve not had your mouth cleaned for a little while…
And we see quite a lot of aliens and flashing lights, and things like that. If a monitor is going off and you can’t see it’s a monitor but you can see a red glow or an orange glow or a blue glow around you (and you must get a feeling of machinery around you), perhaps that’s why that kind of thing happens.
And often somebody trying to kill you – it’s horrible to say it but it’s actually quite a common one…
I suppose sometimes we are doing – well, unpleasant things to our patients; and if you’re half-awake, half-asleep and I’m going ‘OK we just need to put a little drip in…’, is that why you think you’re being hurt?
There are quite a lot of [near-death experiences] as well. ‘I could see somebody calling me but I knew that I couldn’t go there’… ‘I could see myself floating above myself’… we’ve had a couple of people who’ve been able to look down on themselves when things have been being done… that’s very interesting. They’ll say ‘I could see that you were doing this to me’ and you think ‘well, OK, we were, but how much of that is that it’s now been explained to you – and you’ve created an image from your previous experiences, and how much of it is that you could actually kind of see it?’ It’s very hard to unweave the two. But I think it’s the fact that you can’t unweave them that makes them have the impact that they do.
A lot of people do have bad hallucinations, and that’s possibly slightly the majority but for a lot of people they’re… we had one gentleman who thought he was being wheeled through fields and he could just see grass and trees everywhere, and that’s possibly where his accident took place, but that’s what he could see; and he felt quite… he couldn’t quite understand why he was in bed, in the wood, but you know he didn’t feel particularly intimidated or worried about that.
There are so many factors that can cause it: just being really, really ill in itself can cause it; the medications that we use would be some of it; things like not having visual or aural stimulation (that’s why we encourage people to maybe have a radio on or to bring in a bit of music); things like a lack of sleep – lack of natural sleep; obviously if you’ve been sedated for a couple of days, your sense of time goes; …there are things like low or high blood sugars – sodium levels can affect states of consciousness. There are so many different things that can cause it.
So the consensus of our group [of patients and staff] was that we’re never gong to be able to stop them, it’s how we deal with them – and a lot of that is education.
And also I think it’s got to impact on our practice as nurses, to actually approach somebody who is looking terrified of you and trying to maybe find out why… Trying to see whether they respond to a different person better – ‘if somebody else is here will you let me do this?’ Trying to go ‘ok, what’s this person experiencing, how can we make that the best that we can for them?’
It’s a communication thing as well… there was an article published just the other day in The Economist about prisoners who were in prison abroad and didn’t have the same linguistic grouping, and had linguistic isolation; so I’m assuming that for our patients, not being able to communicate, you must a similar kind of isolation, and that’s – that was a predictor actually for auditory hallucinations.
There are so many different theories of hallucinations that there doesn’t seem to be one theory that would explain it all…
I think they have a huge impact on people’s journey. And that’s one of the areas we were looking at – what can we do to minimise the possibilities? Or at least to be able to pick up on them, and to be able to go ‘this is normal, this is happening because…’