Pain management within the palliative and end-of-life care experience in the ICU.
In the ICU where critically ill patients receive aggressive life-sustaining interventions, suffering is common and death can be expected in up to 20% of patients. High-quality pain management is a part of optimal therapy and requires knowledge and skill in pharmacologic, behavioral, social, and communication strategies grounded in the holistic palliative care approach. This contemporary review article focuses on pain management within comprehensive palliative and end-of-life care. These key points emerge from the transdisciplinary review: (1) all ICU patients experience opportunities for discomfort and suffering regardless of prognosis or goals, thus palliative therapy is a requisite approach for every patient, of which pain management is a principal component; (2) for those dying in the ICU, an explicit shift in management to comfort-oriented care is often warranted and may be the most beneficial treatment the health-care team can offer; (3) communication and cultural sensitivity with the patient-family unit is a principal approach for optimizing palliative and pain management as part of comprehensive ICU care; (4) ethical and legal misconceptions about the escalation of opiates and other palliative therapies should not be barriers to appropriate care, provided the intention of treatment is alleviation of pain and suffering; (5) standardized instruments, performance measurement, and care delivery aids are effective strategies for decreasing variability and improving palliative care in the complex ICU setting; and (6) comprehensive palliative care should addresses family and caregiver stress associated with caring for critically ill patients and anticipated suffering and loss.
Center for Health Research, Kaiser Permanente Northwest and Oregon Health & Science University, Portland, OR. Electronic address: Richard.A.Mularski@kpchr.org.
Richard A
RA
Mularski
Critical Care/Trauma Program, Department of Physiological Nursing, University of California, San Francisco, CA.
Kathleen
K
Puntillo
Department of Medicine, Division of Pulmonary and Critical Care, Medical College of Wisconsin, Milwaukee, WI.
Basil
B
Varkey
Department of Pharmacy Practice & Science, University of Arizona College of Pharmacy, Tucson, AZ.
Brian L
BL
Erstad
Adult Health and Nursing Systems Department, School of Nursing, Virginia Commonwealth University, Richmond, VA.
Mary Jo
MJ
Grap
Department of Anesthesiology, Northwestern University Feinberg School of Medicine, Chicago, IL.
Hugh C
HC
Gilbert
Department of Nursing and Health Sciences, College of Science, California State University, East Bay, Hayward, CA.
Denise
D
Li
Professional Practice and Programs, American Association of Critical Care Nurses, Aliso Viejo, CA.
Justine
J
Medina
Pain Management Educator and Clinical Consultant, El Dorado Hills, CA.
Chris
C
Pasero
Virginia Commonwealth University Health System, Richmond, VA.
Curtis N
CN
Sessler
D017028:Caregivers; D003422:Critical Care / Q000941:ethics / Q000592:standards; D003469:Culture; D004992:Ethics, Medical; D006302:Health Services Research; D006801:Humans; D007362:Intensive Care Units / Q000592:standards; D010146:Pain / Q000517:prevention & control*; D010166:Palliative Care / Q000941:ethics / Q000592:standards; D011368:Professional-Family Relations; D011369:Professional-Patient Relations; D011788:Quality of Life; D013727:Terminal Care / Q000941:ethics