title: Unrestricted opiate administration for pain and suffering at the end of life: knowledge and attitudes as barriers to care.
abstract: BACKGROUND
  Pain and symptom management is critical for quality end-of-life care in the hospital. Although guidelines support the use of unrestricted opiate administration to treat refractory pain and suffering in the dying patient, many patients die suffering with symptoms that could have been addressed.
  
  
  METHODS
  A multidisciplinary convenience sample of 381 hospital-based health care providers completed a survey evaluating their understanding of the principles of treating refractory pain and suffering at the end of life in the hospital, knowledge of the institution's policy about how to implement such care, and attitudes about and comfort with such treatment.
  
  
  RESULTS
  Respondents recognized pain and symptom management as a goal of unrestricted opiate use at the end of life, but 12% identified comfort for families or treatment of nonphysical suffering as the principal goal of this modality. Two thirds of respondents felt that unrestricted opiates were used too rarely and 45% felt they were used too late. However, 16% felt uncomfortable administering unrestricted opiates and 21% of physicians and nurses who had used restricted opiates reported having felt pressured to increase dosing of opiates. Knowledge deficits concerning appropriate candidates for unrestricted opiates and the protocol for appropriate implementation were common.
  
  
  CONCLUSIONS
  Knowledge deficits and attitudinal concerns may hamper the administration of unrestricted opiates for refractory pain and suffering at the end of life in the hospital. Clinician education and clarification of the appropriate use of this modality when there are differences in clinician and family perception of discomfort are needed.
authors.affiliation: Division of General Internal Medicine and Health Services Research, David Geffen School of Medicine at UCLA, Los Angeles, California 90024-1736, USA.
authors.forename: Iris Cohen
authors.initials: IC
authors.lastname: Fineberg
authors.forename: Neil S
authors.initials: NS
authors.lastname: Wenger
authors.forename: Katherine
authors.initials: K
authors.lastname: Brown-Saltzman
mesh_terms: D000293:Adolescent; D000368:Aged; D000369:Aged, 80 and over; D000701:Analgesics, Opioid / Q000008:administration & dosage / Q000627:therapeutic use*; D001291:Attitude of Health Personnel; D003657:Decision Making; D005260:Female; D006291:Health Policy; D006801:Humans; D007231:Infant, Newborn; D008297:Male; D008875:Middle Aged; D009741:Nursing Staff, Hospital / Q000523:psychology*; D010146:Pain / Q000145:classification / Q000188:drug therapy*; D010818:Practice Patterns, Physicians'; D012720:Severity of Illness Index; D013727:Terminal Care / Q000523:psychology*
chemical_list: D000701:Analgesics, Opioid