Pain Assessment in Noncommunicative Adult Palliative Care Patients

Cette étude s’est intéressée à l’intervention des équipes mobiles de soins palliatifs dans des services de gériatrie.

Sur une période de 6 mois, nous avons inclus des patients hospitalisés en gériatrie pour lesquels l’équipe mobile de soins palliatifs avait été sollicitée. Les données ont été recueillies de manière rétrospective.

À la fin du recueil, 190 patients ont été inclus. L’âge moyen était de 89 ans. Ils étaient atteints d’une polypathologie dans la moitié des cas et d’un cancer dans 22,6 % des cas. Les deux principaux motifs d’appel étaient une demande d’aide à la prise en charge des symptômes et d’aide à la décision. La douleur était le principal symptôme observé lors de l’évaluation initiale. Il y a eu 80 % de décès et 22,1 % de transferts en unité de soins palliatifs à la fin du recueil.

Le recours aux soins palliatifs était souvent tardif, notamment chez les patients non cancéreux. Identifier précocement des éléments orientant vers une prise en charge palliative pourrait permettre d’améliorer le suivi des patients atteints de pathologies chroniques. À titre d’exemple, le « Pallia10 Géronto » est un outil d’aide pour un recours précoce en soins palliatifs.

Les équipes mobiles de soins palliatifs ont un rôle important pour accompagner les équipes de gériatrie dans la prise en charge des patients âgés relevant de soins palliatifs.

This study concerns the intervention of a Mobile Palliative Care Team in geriatric wards.

Over 6 months we studied geriatric inpatients for whom the Mobile Palliative Care Team was called upon. Retrospective data was collected.

At the end of the follow-up, 190 inpatients were included. The mean age was 89. The main diagnosis was polypathology for half of the individuals included and 22.6% had cancer. The main reasons for referral were symptoms and decisional support. Pain was the main symptom at the first assessment. After 6-months follow-up, 80% had died and 22,1% were transferred to Palliative Care Units.

The moment of referral to palliative care was late in the care provision, especially for non-cancerous people. Early detection of criteria for palliative care could improve the management of chronic disease. For example, the “Pallia10 Geronto” is a tool to help early referral to palliative care.

The purpose of the Mobile Palliative Care Team is to assist geriatric teams in taking care of elderly patients with palliative needs.

Central to palliative care is the early assessment and treatment of pain, whether physical, psychosocial, or spiritual. Nonverbal palliative care patients are at risk for inadequate pain assessment leading to prolonged suffering.

The purpose of this project was to implement and evaluate an evidence-based pain assessment tool for nonverbal palliative care patients.

The Iowa Model Revised: Evidence-Based Practice to Promote Excellence in Healthcare and the Implementation Strategies for Evidence-Based Practice Guide provided the guiding frameworks.

On a six-bed adult inpatient Palliative Care Unit (PCU).

Nonverbal palliative care patients.

Evidence supported use of the Multidimensional Objective Pain Assessment Tool (MOPAT) for nonverbal patients receiving palliative care. During an eight-week pilot, nurses recorded pain assessments on a paper form and trended pain scores over a 24-hour period. Evaluation included knowledge, attitudes, and behaviors pre- and post-pilot and was subsequently used in a Precision Implementation Approach to promote adoption.

Nurses’ attitudes toward palliative care pain assessment improved in all items on the evaluation tools. Pain was assessed using MOPAT for 74% of nonverbal palliative care patients and 88% of patients had linked pain interventions to MOPAT scores.

MOPAT is the only valid evidence-based pain assessment tool for nonverbal patients receiving palliative care. This project led to successful adoption of the MOPAT within the PCU.

The major ethical dilemma regarding feeding a person at the end of their life in Israel is related to the medical team's ability to not provide food. In addition to the medical indications, the decision-making process needs to include ethnic considerations, religious positions and a strong collective memory related to the Holocaust and post-Holocaust behavior. An Expert group of professionals regularly faced with these dilemmas gathered to address this issue. The group included Nutrition Specialists, Neurologists, Geriatricians, Oncologists and Specialists in palliative care, Nurses, Dieticians, Speech therapists but also Lawyers and Religion experts.

The conclusions suggested: 1) One should evaluate the patient's ability to eat safely and sufficiently, assessed by speech therapist and dietician evaluations. 2) If not successful, a discussion between the team, the patient, if available, and the family is initiated. 3) If oral nutrition is possible it is encouraged. 4) If not, artificial nutrition should be discussed. 5) The family's will to never stop providing food and water according to Jewish law has to be acknowledged when the medical team does not suggest nutritional therapy. Emotional aspects, religious beliefs and nutritional indications have to be reconciled and a consensus should be reached.

A prospective study was performed on hospitalized conscious dogs. The objectives were: 1) to evaluate the feasibility and reliability of portable infrared pupillometry using a measure of photo light reflexes, 2) to identify parameters influencing measures, and 3) to compare parameters before and after the administration of analgesia.

Twenty-nine dogs were included. Pupillometry was feasible by a single person. There was an excellent reliability for the evaluation of pupil diameter. There was poor to good reliability for the other parameters. There was an association between weight and mean pupil diameter (estimate = 0.1 mm, CI95 = [0.0; 0.1], P = 0.02), mean diameter variation (estimate = 0.2%, CI95 = [0.0; 0.4], P = 0.01), and mean velocity (estimate = 0.08 ms, CI95 = [0.03; 0.13], P = 0.002). Male dogs had a significantly larger mean pupil diameter than females (estimate = 1.3 mm, CI95 = [0.1; 2.5], P = 0.03). Independently of weight and sex, there was an association between mean pupil diameter and pain score: the higher the pain score, the lower the mean pupil diameter. There was a correlation between mean pupil diameter and morphine dose (ρ = −0.78, P = 0.0004). There was no significant difference in pupil diameter, velocity, and latency before and after analgesic administration.

In conclusion, results do not support the use of PLR measurement by pupillometry as a pain assessment technique in hospitalized conscious dogs.

Pain is the most common symptom in chronic pancreatitis (CP) with a major impact on quality of life. Few validated questionnaires to assess pain in CP exist, and the lack of consensus negatively impacts clinical management, research and meta-analysis. This guideline aims to review generic pain questionnaires for their usability in CP, to outline how pain assessment can be modified by confounding factors and pain types, to assess the value of additional measures such as quality of life, mental health and quantitative sensory testing, and finally to review pain assessment questionnaires used specifically in CP. A systematic review was done to answer 27 questions that followed the PICO (Population; Intervention; Comparator; Outcome) template. Quality of evidence of the statements was judged by Grades of Recommendation, Assessment, Development and Evaluation (GRADE) criteria. The manuscript was sent for review to 36 experts from various disciplines and continents in a multi-stage Delphi process, and finally reviewed by patient representatives. Main findings were that generic pain instruments are valid in most settings, but aspects of pain are specific for CP (including in children), and instruments have to account for the wide phenotypic variability and development of sensitization of the central nervous system. Side effects to treatment and placebo effects shall also be considered. Some multidimensional questionnaires are validated for CP and are recommended together with assessment of quality of life and psychiatric co-morbidities. This guideline will result in more homogeneous and comprehensive pain assessment to potentially improve management of painful CP.

The current study aimed to examine nurses’ critical thinking and decision-making skills related to pain management and their association with nurses’ characteristics.

This descriptive correlational study used a convenience sample of 115 critical care nurses working in a university hospital in Jordan. Data were collected using a pain-related vignette and validated questionnaires.

The Critical Thinking Self-Assessment Scale and the Nursing Decision-Making Instrument were used to measure the nurses’ critical thinking and decision-making skills, respectively. As a secondary outcome measure, data regarding the sociodemographic/professional characteristics of the participants, including gender, marital status, experience, education and work environment, were collected.

The participating nurses reported poor critical thinking and intuitive decision-making skills related to pain management. Nurses with more clinical experience and higher levels of education reported significantly better critical thinking and intuitive decision-making skills than less experienced and less educated nurses. Nurses with intuitive decision-making modes reported significantly better levels of critical thinking than nurses with analytical or flexible analytical-intuitive decision-making modes.

Critical care nurses were found to have ineffective critical thinking and intuitive decision-making skills related to pain management, which may lead to poor patient outcomes. Gaining more in-depth understanding of nurses’ critical thinking and decision-making skills and their associated factors is crucial for achieving effective pain management in critical care settings.