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Postgraduate Education Corner: CONTEMPORARY REVIEWS IN CRITICAL CARE MEDICINE |

Pain Management Within the Palliative and End-of-Life Care Experience in the ICU

Richard A. Mularski, MD, MSHS, MCR, FCCP; Kathleen Puntillo, RN, CNS, DNSc; Basil Varkey, MD, FCCP; Brian L. Erstad, PharmD; Mary Jo Grap, PhD, RN; Hugh C. Gilbert, MD; Denise Li, PhD, RN, CNS; Justine Medina, RN, MS; Chris Pasero, MS, RN-BC; Curtis N. Sessler, MD, FCCP; Center for the Evaluative Clinical Sciences at Dartmouth Medical School
Author and Funding Information

*From The Center for Health Research (Dr. Mularski), Kaiser Permanente Northwest and Oregon Health & Science University, Portland, OR; Critical Care/Trauma Program, Department of Physiological Nursing (Dr. Puntillo), University of California, San Francisco, CA; the Department of Medicine (Dr. Varkey), Division of Pulmonary and Critical Care, Medical College of Wisconsin, Milwaukee, WI; the Department of Pharmacy Practice & Science (Dr. Erstad), University of Arizona College of Pharmacy, Tucson, AZ; Adult Health and Nursing Systems Department (Dr. Grap), School of Nursing, Virginia Commonwealth University, Richmond, VA; the Department of Anesthesiology (Dr. Gilbert), Northwestern University Feinberg School of Medicine, Chicago, IL; the Department of Nursing and Health Sciences (Dr. Li), College of Science, California State University, East Bay, Hayward, CA; Professional Practice and Programs (Ms. Medina), American Association of Critical Care Nurses, Aliso Viejo, CA; Pain Management Educator and Clinical Consultant (Ms. Pasero), El Dorado Hills, CA; and Virginia Commonwealth University Health System (Dr. Sessler), Richmond, VA.

Correspondence to: Richard A. Mularski, MD, MSHS, MCR, FCCP, Clinical Investigator, The Center for Health Research, Kaiser Permanente Northwest, Clinical Assistant Professor of Medicine, Pulmonary & Critical Care Medicine, Oregon Health & Science University, 3800 N Interstate, WIN 1060, Portland, OR 97227; e-mail: Richard.A.Mularski@kpchr.org


This article focuses on pain therapy as part of optimal palliative and end-of-life care in the ICU. Other manuscripts in this series focus on assessment, pharmacologic treatment, nondrug therapy, and structured approaches for comprehensive pain management in the ICU.

Dr. Puntillo has no relationships with industry but makes formal presentations at professional societies that are sometimes sponsored by industry. She has no personal contact with industry personnel or others that make those arrangements. Dr. Varkey served as a speaker and in an advisory board meeting for Astra Zeneca in August 2008. Ms. Pasero discloses that her lectures, which cover general pain management, do not promote any products or equipment and are occasionally supported by industry (Baxter Healthcare Corporation, Ortho McNeil, and Johnson & Johnson). She is paid as a consultant to critique pain management products in development (ie, Alpharma and Johnson & Johnson), and to answer general pain management questions of industry customers, such as nurses, pharmacists, and physicians (Baxter Healthcare Corporation and Cardinal Health). She also develops patient education materials (Endo Pharmaceutical). Dr. Sessler received a grant from Physiometrix, and has served as a consultant and on the advisory committee for Hospira. Drs. Mularski, Erstad, Grap, Gilbert, and Li, and Ms. Medina have reported to the ACCP that no significant conflicts of interest exist with any companies/organizations whose products or services may be discussed in this article.

Reproduction of this article is prohibited without written permission from the American College of Chest Physicians (www.chestjournal.org/site/misc/reprints.xhtml).


© 2009 American College of Chest Physicians


Chest. 2009;135(5):1360-1369. doi:10.1378/chest.08-2328
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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.


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