Palliative Care and Pain Management at the End of Life ___________________________________________
BEHAVIORS TO EVALUATE IN ASSESSING PAIN IN CHILDREN AND ADOLESCENTS
Age of Child
Behaviors
Infants (<1 year)
Sleep during the previous hour Facial expressions (frown, furrowed brow, quivering chin) Consolability Crying Sucking Flexing of fingers and toes
Motor activity Breath-holding
Children (1 year and older)
Energy level Eating behavior Interest in usual activities Whining, crying, groaning, complaining Holding or protecting part of body Seeking comfort, closeness
Source: [450; 494; 495; 498; 501]
Table 28
for surrogate decision making [514; 516; 517]. As these fac- tors gain greater recognition, there is a growing emphasis on integrating palliative care elements into the care of patients with traumatic injury and/or patients in an ICU [122; 514; 516; 517; 518; 519]. The focus on complex, lifesaving care in the ICU creates a gap in providing relief of patients’ symptoms. As in all settings, symptom assessment and management should be a priority for ICU patients. It has been suggested that an interdisciplinary palliative care assessment be carried out early in an ICU stay, preferably within 24 hours after admission, with documen- tation of a comprehensive care plan within 72 hours after admission [517; 520]. ICU patients are often young, and families expect lifesaving procedures to be effective [517]. Misunderstanding of lifesaving measures has been reported to be an obstacle to high-quality palliative care [521]. Clinicians and other members of the team should maintain open, ongoing communication about the patient’s prognosis, the feasibility of recovery, and the burden of treatment. The sudden, often catastrophic events that bring patients to the ICU compound stress and grief in family members, whose psychosocial needs peak earlier than in other palliative care settings [517]. As a result, psychosocial and bereavement support for families must begin early in the course of the patient’s stay in the ICU, preferably within 24 hours after the patient’s admission to the ICU [517]. The abruptness of traumatic injury or catastrophic illness is also associated with the lack of preparation of advance direc- tives for many patients. There is often no time for planning during the short end-of-life process, and approximately 95% of patients are unable to participate in their care [517]. As a consequence, surrogates must make decisions, and such deci- sions have been shown to correlate poorly with the preferences of patients [522; 523].
The most critical decision in the ICU setting is the withdrawal of life-support technologies. Withdrawal of mechanical ventila- tor support should be discussed with the family or surrogate when they (or the patient) raise the issue or when the clinician believes that the ventilator is no longer meeting the patient’s goals or is more burdensome than beneficial [122]. To ease the discussion for families, the clinician should review the patient’s status and care goals before discussing withdrawal of support [122]. Once the decision has been made to withdraw life support, the physician should review the process with family members, clarify the decision, ensure that the patient’s spiritual and cultural context are considered, and reassure the family that comfort measures will be carried out [122; 517]. Withdrawal of life support should then be immediate, not carried out over hours or days, and established protocols for withdrawal of mechanical ventilation should be followed [517; 524]. Recognizing the importance of palliative care in critical care settings, the Society of Critical Care Medicine developed rec- ommendations calling for, among other improvements, [514]: • Increased competency in all aspects of palliative care, including the use of sedatives, analgesics, and non- pharmacologic approaches to manage symptoms • Improved communication with family • Better understanding of the practical and ethical aspects of withdrawing life-sustaining treatment • Development of comprehensive bereavement programs to support both families and the needs of the clinical staff
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MDCA1525
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