___________________________________________ Palliative Care and Pain Management at the End of Life
• Using the oral form of medication whenever possible • Dosing analgesics at regular intervals • Administering analgesics based on the severity of pain assessed using a pain-intensity scale • Tailoring medication dosing to the individual patient • Monitoring the patient carefully throughout the pre- scription of pain medications Acetaminophen or NSAIDs, codeine, or oxycodone is rec- ommended for pain rated as 0–3 on a scale of 0 to 10; an acetaminophen/opioid combination, NSAIDs, oxycodone, or morphine is recommended for pain rated as 4–6; and morphine or oxycodone is recommended for pain rated as 7–10 [187]. It is important to note that codeine may not be metabolized in 35% of children, and analgesia will be ineffec- tive in those children [187]. Pharmacokinetic data for pedi- atric medications are lacking, and physicians should consult pediatric specialists for appropriate dosing of medications for symptom relief. Pain medication should be complemented by age-appropriate nonpharmacologic interventions; touch, mas- sage, stroking, and rocking are effective for infants, toddlers, and young children, and guided imagery, music and art therapy, play therapy, controlled breathing, and relaxation techniques are beneficial for older children [493; 506; 507]. Attention to psychosocial support for the patient, parents, and other family members is crucial in the pediatric setting. Although most parents think that psychosocial issues should be discussed with the child’s physician and would find that discussion to be valuable, fewer than half of parents raise such topics [508]. Furthermore, parents report that only 15% to 20% of physicians assess the family’s psychosocial issues [508]. Among the psychosocial issues common in children/ adolescents and their families are ineffective family coping strategies, the patient’s relationships with peers, psychological adjustment of healthy siblings, and long-term psychological adjustment for parents [484; 506; 509; 510; 511; 512; 513]. The palliative care team must carefully evaluate the patient and family and provide resources and appropriate referrals. CRITICAL CARE SETTING Nearly 50% of patients who die in the hospital are in the ICU for some period of time during the last three days of life [514; 515]. In addition, 13% of patients admitted to the ICU with traumatic injury will die [514]. The abruptness of a traumatic injury is vastly different from the illness trajectories of life-limiting diseases, and palliative care seems incongru- ous in the ICU, a high-technology environment of the most aggressive life-prolonging treatments. The effective delivery of palliative care is challenged by many factors inherent in the ICU setting, including inadequate training of healthcare professionals, unrealistic expectations of patients and families, misunderstanding of lifesaving measures, and a greater need
As with adults, the patient’s self-report of pain is the most reli- able indicator, which makes assessment particularly challenging in young children [67; 493]. Pain assessment must be appro- priate for each child’s age, developmental level, and cultural context, and assessment tools have been developed for four age groups, from infants to 18 years of age, and for nonverbal or cognitively impaired children [494; 495; 496]. These tools include lists of behaviors for the parents or caregivers to rate, as well as areas for parents to provide their own rating of the child’s pain and to note what has previously helped to allevi- ate pain ( Table 28 ). The tools for children who are 5 years of age and older include age-appropriate items such as drawings of a child’s body on which the child is asked to mark with a crayon or pencil the area that hurts and different sized circles to indicate pain intensity. A variety of pain scales (e.g., self- report scale, numerical/visual analogue scale, FACES scale) and other tools (e.g., Pediatric Pain Questionnaire) for assessing and measuring pain in children are available at https://www. aboutkidshealth.ca/Article?contentid=2994&language=Engl ish [497]. The Wong-Baker FACES scale is recommended for children who are at least 3 years of age [243]. This scale has been found to be valid and reliable for Japanese, Thai, Chinese, and Black children and has been modified for use with Alaska native children [498; 499; 500]. For children who are too young to verbally express pain, clini- cians and parents must rely on behavioral cues, such as frown- ing, a furrowed brow, a quivering chin, crying, sucking, flexing of fingers and toes, and breath-holding in infants. Behavioral indicators in older children include decreased energy level, eating, and interest in usual activities; holding or protecting part of the body; seeking comfort or closeness; and whining or groaning [494; 495; 496]. Pain management according to the WHO ladder has been found to be effective for children/adolescents [502; 503; 504; 505]. The main components of the WHO strategy include [504; 505]: PREVALENCE OF SYMPTOMS AMONG CHILDREN IN THE LAST MONTH OF LIFE Symptom Range in Prevalence Pain 73% to 92% Fatigue/weakness 86% to 91% Anorexia 68% to 81% Reduced mobility 61% to 76% Nausea/vomiting 57% to 63% Constipation 55% to 59% Anxiety/depression 45% to 48% Dyspnea 41% to 81% Source: [481; 490; 491] Table 27
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