The majority of existing clinical guidelines and consensus statements on pain management at the end of life in the intensive care unit (ICU) agree on a set of recommendations that include the use of high doses of opioid and the adoption of a quantitative way to assess pain, according to a systematic review published in Critical Care Medicine.
In this systematic review, data were collected on several recommendations for end-of-life pain management in the ICU, including initial drug dosing, titration, maximum dose, and route of administration, side effect management, the principle of “double effect,” the use of neuromuscular blockers, and palliative care consultation.
The review examined 10 full-text guideline and consensus statement articles on recommendations for end-of-life pain management in the ICU. Most articles agreed on the use of a quantitative tool for pain assessment in terminally ill patients in the ICU, such as a quantitative symptom or functional scale. Other scales for quantitative pain assessment included the Pain Assessment Behavioral Scale, the Sedation Agitation Scale, the Visual Analog Scale for conscious patients, the Campbell scale for unconscious patients, and bispectral index monitoring.
The use of narcotics for pain relief and of benzodiazepines to relieve anxiety was recommended in the majority of articles reviewed. In 2 articles, the use of nonpharmacologic pain management strategies, such as spiritual assistance and family support was recommended. Many articles advised against the use of neuromuscular blockers during withdrawal of life support, as this may hamper the assessment of pain, with one article describing such an approach as unethical. The use of high doses of opioids and sedatives for pain management was also endorsed in most publications.
Study limitations include the heterogeneity in the methodology used in the articles reviewed.
”There is a need to develop quality improvement strategies and to produce evidence-based pain management strategies, as well as to explore the most effective method for pain assessment in the critically ill patient at the end of life and the role of new analgesics and nonpharmacologic measures for pain management in this setting,” concluded the review authors.
Durán-Crane A, Laserna A, López-Olivo MA, et al. Clinical practice guidelines and consensus statements about pain management in critically ill end-of-life patients: a systematic review [published online September 12, 2019]. Crit Care Med. doi: 10.1097/CCM.0000000000003975