Aromatherapy 77
Use of plant and herb-based essential oils (indirect inhalation via room diffuser, direct inhalation, aromatherapy massage, or applying essential oils to the skin). Several small studies suggest that the presence of a dog reduces aggression and agitation, as well as promoting social behavior in people with dementia.
Pet therapy 76,78
Interventions should be matched to the specific needs and capabilities of the patient, and they can be used concurrently with any medications that might be employed. 71,72 CAT interventions are aimed at reducing pain, inducing relaxation, and enhancing a sense of control over the pain or the underlying disease. Breathing exercises, relaxation, imagery, hypnosis, and other behavioral therapies are among the modalities shown to be potentially helpful to patients. 41 Physical modalities such as massage, use of heat or cold, acupuncture, acupressure, and other physical methods may be provided in consultation with physical or occupational therapy. These treatments can enhance patients’ sense of control as well as greatly reduce the family caregivers’ sense of helplessness when they are engaged in pain relief. One study found that both massage and “simple touch” induced Managing Pain in Intensive Care Units Several studies show that most US adults wish to die at home. 82 And yet more than half of deaths occur in hospitals, most with ICU care. 83 When curative approaches are not expected to be successful, a transition to primary comfort-focused care and the withdrawal of ineffective or burdensome therapies is often the compassionate course. Although guidelines and detailed strategies have been developed for analgesic therapy during the removal of life-sustaining interventions, communication about what to expect and how things may proceed remain paramount to negotiating this care transition. 84 Some patients and families may be able to have meaningful interactions at the end of life, and thus brief interruption of sedatives and analgesics may be reasonable. Rarely are dying ICU patients able to self-report information about their pain. 84 Thus it is incumbent on the critical care health professionals, perhaps with the
statistically significant improvements in pain, quality of life, and physical and emotional symptom distress over time without increasing analgesic medication use. 79 Psychosocial interventions for end-of-life pain may include cancer pain education, hypnosis and imagery based methods, and coping skills training. 80 Educational programs are one of the most common interventions to address cancer pain barriers, and current studies provide high-quality evidence that pain education is feasible, cost-effective, and practical in end-of-life settings. 80 Coping skills training may be beneficial for patients and family caregivers dealing with chronic cancer pain, although the dose and components of a coping skills training regimen remain uncertain. Other integrative and behavioral approaches found to be helpful for managing end-of-life pain are massage therapy and acupuncture. 81 assistance of the patient’s family members, to assess pain without self-report input from the patient. Two pain assessment instruments have been validated for use in the ICU setting: the Behavioral Pain Scale 85 and the Critical-Care Pain Observation Tool. 86 Both tools describe specific observations that the patient’s ICU care providers (including family members or loved ones) can make that, when present, could indicate the patient is experiencing pain such as grimacing, rigidity, wincing, shutting of eyes, clenching of fists, verbalization, and moaning. 87 Reports by family members or other people close to a patient should not be overlooked. In the Study to Understand Prognosis and Preference for Outcomes and Risks of Treatment (SUPPORT) study, surrogates for patients who could not communicate verbally had a 73.5% accuracy rate in estimating presence or absence of the patient’s pain. 88
MANAGING COMMON EOL SYMPTOMS
Effective symptom control can allow patients at the end of their lives to pass through the dying process in a safe, dignified, and comfortable manner. When possible, proactive regimens to prevent symptoms should be used since it is generally easier to prevent symptoms than treat acute symptoms. Because disrupted swallowing function and changes in levels Nutrition and Hydration The provision of nutrition and hydration can become a clinical challenge at the end of life and can be directly related to the use of analgesics, particularly in decisions about the preferred route of analgesic administration. As with decisions about analgesia itself, the fundamental question regarding various alternatives for nutrition or hydration is whether the potential benefits outweigh the burdens from the
of consciousness can affect patients’ ability to swallow pills, medications must be provided in formulations that are safe and feasible for administration. Concentrated sublingual medications, dissolvable tablets, transdermal patches, creams or gels, and rectal suppositories can be used in patients with impaired swallowing or decreased responsiveness. patient’s perspective. The patient’s own expression of interest should be the primary guide. If a dying patient shows interest in either food or fluids, they should never be withheld unless providing them clearly causes greater suffering (i.e., in patients for whom oral feeding causes significant discomfort). 39 In most cases, patients either do not show an active interest in food or are satisfied with very small amounts
Book Code: CA23CME
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