title: Palliative care in the ICU: relief of pain, dyspnea, and thirst--a report from the IPAL-ICU Advisory Board.
abstract: OBJECTIVE
  Pain, dyspnea, and thirst are three of the most prevalent, intense, and distressing symptoms of intensive care unit (ICU) patients. In this report, the interdisciplinary Advisory Board of the Improving Palliative Care in the ICU (IPAL-ICU) Project brings together expertise in both critical care and palliative care along with current information to address challenges in assessment and management.
  
  
  METHODS
  We conducted a comprehensive review of literature focusing on intensive care and palliative care research related to palliation of pain, dyspnea, and thirst.
  
  
  RESULTS
  Evidence-based methods to assess pain are the enlarged 0-10 Numeric Rating Scale (NRS) for ICU patients able to self-report and the Critical Care Pain Observation Tool or Behavior Pain Scale for patients who cannot report symptoms verbally or non-verbally. The Respiratory Distress Observation Scale is the only known behavioral scale for assessment of dyspnea, and thirst is evaluated by patient self-report using an 0-10 NRS. Opioids remain the mainstay for pain management, and all available intravenous opioids, when titrated to similar pain intensity end points, are equally effective. Dyspnea is treated (with or without invasive or noninvasive mechanical ventilation) by optimizing the underlying etiological condition, patient positioning and, sometimes, supplemental oxygen. Several oral interventions are recommended to alleviate thirst. Systematized improvement efforts addressing symptom management and assessment can be implemented in ICUs.
  
  
  CONCLUSIONS
  Relief of symptom distress is a key component of critical care for all ICU patients, regardless of condition or prognosis. Evidence-based approaches for assessment and treatment together with well-designed work systems can help ensure comfort and related favorable outcomes for the critically ill.
authors.affiliation: University of California at San Francisco, San Francisco, CA, USA.
authors.forename: Kathleen
authors.initials: K
authors.lastname: Puntillo
authors.affiliation: Icahn School of Medicine at Mount Sinai, New York, NY, USA. judith.nelson@mssm.edu.
authors.forename: Judith Eve
authors.initials: JE
authors.lastname: Nelson
authors.affiliation: Medical College of Wisconsin, Milwaukee, WI, USA.
authors.forename: David
authors.initials: D
authors.lastname: Weissman
authors.affiliation: University of Washington, Seattle, WA, USA.
authors.forename: Randall
authors.initials: R
authors.lastname: Curtis
authors.affiliation: Icahn School of Medicine at Mount Sinai, New York, NY, USA.
authors.forename: Stefanie
authors.initials: S
authors.lastname: Weiss
authors.affiliation: Cleveland Clinic, Cleveland, OH, USA.
authors.forename: Jennifer
authors.initials: J
authors.lastname: Frontera
authors.affiliation: Veteran's Administration Palo Alto, Palo Alto, CA, USA.
authors.forename: Michelle
authors.initials: M
authors.lastname: Gabriel
authors.affiliation: University of Washington, Seattle, WA, USA.
authors.forename: Ross
authors.initials: R
authors.lastname: Hays
authors.affiliation: North Shore-Long Island Jewish Health System, Hyde Park, NY, USA.
authors.forename: Dana
authors.initials: D
authors.lastname: Lustbader
authors.affiliation: University Medical and Dental of New Jersey, Newark, NJ, USA.
authors.forename: Anne
authors.initials: A
authors.lastname: Mosenthal
authors.affiliation: Hartford Hospital, Hartford, CT, USA.
authors.forename: Colleen
authors.initials: C
authors.lastname: Mulkerin
authors.affiliation: Lehigh Valley Health Network, Allentown, PA, USA.
authors.forename: Daniel
authors.initials: D
authors.lastname: Ray
authors.affiliation: St. Luke's Hospital, Boise, ID, USA.
authors.forename: Rick
authors.initials: R
authors.lastname: Bassett
authors.affiliation: Johns Hopkins University School of Medicine, Baltimore, MD, USA.
authors.forename: Renee
authors.initials: R
authors.lastname: Boss
authors.affiliation: Medical College of Wisconsin, Milwaukee, WI, USA.
authors.forename: Karen
authors.initials: K
authors.lastname: Brasel
authors.affiliation: Wayne State University College of Nursing, Detroit, MI, USA.
authors.forename: Margaret
authors.initials: M
authors.lastname: Campbell
mesh_terms: D003422:Critical Care / Q000592:standards*; D004417:Dyspnea / Q000175:diagnosis / Q000628:therapy*; D006801:Humans; D007362:Intensive Care Units; D059408:Pain Management; D010147:Pain Measurement; D010166:Palliative Care; D058996:Quality Improvement; D013894:Thirst