Search

The article addresses criticisms of the Defense and Veterans Pain Rating Scale (DVPRS), emphasizing its development process involving service members and its extensive utilization across different care settings. It details the scale's rigorous evaluation, its alignment with patient needs, and challenges assertions questioning its reliability and validity.

Objective This study evaluated the association between pain outcomes and post-traumatic stress disorder (PTSD) symptom trajectories after combat-related injury, while adjusting for receipt of regional anesthesia (RA) soon after injury. Methods The PTSD symptom trajectories of N = 288 combat-injured service members were examined from within a month of injury up to two-years after. Linear mixed-effects models evaluated the association between PTSD symptom trajectories and average pain and pain interference outcomes while adjusting for receipt of RA during combat casualty care. Results Four PTSD trajectories were characterized: resilient, recovering, worsening, and chronic. Differential pain presentations were associated with PTSD symptom trajectories, even after adjusting for receipt of RA. Compared to those with a resilient PTSD symptom trajectory, individuals presenting with chronic PTSD trajectories were estimated to experience average pain scores 2.61 points higher (95% CI: 1.71, 3.14). Participants presenting with worsening (β = 1.42; 95% CI: 0.77, 1.78) and recovering PTSD trajectories (β = 0.65; 95% CI: 0.09, 1.08) were estimated to experience higher average pain scores than participants with resilient PTSD trajectories. Significant differences in pain interference scores were observed across PTSD trajectories. Receiving RA was associated with improved pain up to two years after injury (β = -0.31; 95% CI: -0.90, -0.04), however no statistically significant association was detected between RA and PTSD trajectories. Conclusions Chronic and worsening PTSD trajectories were associated with greater pain intensity and interference following combat injury even when accounting for receipt of early RA for pain management. These findings underscore the need to jointly assess pain and PTSD symptoms across the trauma care continuum. [ABSTRACT FROM AUTHOR]

Untreated pain and pain management with opioids are independent precipitating factors for delirium. This retrospective study evaluated the relationships among pain severity, its management with opioids, and the onset of delirium in older adult patients admitted to the surgical intensive care unit (SICU). Consecutive patients aged 65 or greater admitted to the SICU over a 5-month period were examined (n = 172). When assessed using a multivariable general estimating equation model, opioids (chi-square [χ2], 12.34, p =.0004), but not pain (χ2, 3.31, p =.0688) were significant in predicting next-day delirium status. Controlling for pain, patients exposed to opioids were 2.5 times more likely to develop delirium than patients not exposed (95% Confidence Interval: 1.44–4.36). Our data shows that opioid administration predicted the onset of next-day delirium. In an effort to prevent delirium, future research should focus on opioid-sparing pain management approaches to mitigate pain and delirium. [ABSTRACT FROM AUTHOR]

Objective Acute neuropathic pain is a significant diagnostic challenge, and it is closely related to our understanding of both acute pain and neuropathic pain. Diagnostic criteria for acute neuropathic pain should reflect our mechanistic understanding and provide a framework for research on and treatment of these complex pain conditions. Methods The Analgesic, Anesthetic, and Addiction Clinical Trial Translations, Innovations, Opportunities, and Networks (ACTTION) public–private partnership with the U.S. Food and Drug Administration (FDA), the American Pain Society (APS), and the American Academy of Pain Medicine (AAPM) collaborated to develop the ACTTION-APS-AAPM Pain Taxonomy (AAAPT) for acute pain. A working group of experts in research and clinical management of neuropathic pain was convened. Group members used literature review and expert opinion to develop diagnostic criteria for acute neuropathic pain, as well as three specific examples of acute neuropathic pain conditions, using the five dimensions of the AAAPT classification of acute pain. Results AAAPT diagnostic criteria for acute neuropathic pain are presented. Application of these criteria to three specific conditions (pain related to herpes zoster, chemotherapy, and limb amputation) illustrates the spectrum of acute neuropathic pain and highlights unique features of each condition. Conclusions The proposed AAAPT diagnostic criteria for acute neuropathic pain can be applied to various acute neuropathic pain conditions. Both the general and condition-specific criteria may guide future research, assessment, and management of acute neuropathic pain. [ABSTRACT FROM AUTHOR]

Planning and coordination among health-care professionals decrease readmission rates, yet workers have few opportunities to learn interprofessionally to improve transitions of care. An interprofessional readmission review curriculum engaged medical residents, pharmacy residents, nurse practitioner students, early-career nurses, and social work students in a critical analysis of readmissions. Learners (N = 98) participated in a 2 h, collaborative learning session to review health records from a patient readmitted within 30 days of discharge and determine plausible root causes for readmissions. A 5-item post-session survey completed by 83 (85%) evaluated knowledge and perceived competencies in transitions of care before and after participation. Significant improvements (p <.001) occurred in ratings for all five items. Two open-ended questions captured learners' perceptions of understanding and appreciating the roles of other disciplines in the discharge process and importance of interprofessional communication. Several themes emerged including understanding gaps in the discharge process, improving interprofessional collaboration and communication, and paying more attention to discharge documentation. This innovative program helped build essential skills to ensure safe discharges by introducing learners to interprofessional perspectives in analyzing root causes for readmissions, strategies to improve discharge planning, and the value of team-based care. [ABSTRACT FROM AUTHOR]

Clinicians routinely perform bone marrow aspiration and biopsy (BMAB) to diagnose cancer and evaluate disease status; however, few studies address pain and distress with BMAB. A prospective descriptive–correlational design examined patients' (N = 152) ratings of pain intensity (numeric rating scale, 0-10) and distress (distress thermometer) at baseline and 5 min and 1 hr postprocedure. Data were analyzed using descriptive statistics, chi-square, and linear regression models. Mean postprocedure pain intensity at 5 min was moderate, 5.56 (SD = 3.03), and opioid use was associated with decreased pain at 1 hr (p <.001). Preprocedure administration of anxiolytics had no significant effect on distress reduction (p =.88). Being female, first-time biopsy, and increased preprocedure pain were significant predictors of postprocedure distress (p <.001). Treating anxiety alone may not be sufficient to lessen pain and distress. Individualized plans of care should be based on patient risk and response to procedure. [ABSTRACT FROM AUTHOR]

Objective: To evaluate the feasibility and impact of implementing the "study of patient-nurse effectiveness with assisted communication strategies-2" (SPEACS-2); a program to facilitate communication with nonvocal patients. Study Design: The plan-do-study-act quality improvement methodology guided the implementation of a modified SPEACS-2 program within a pre and posttest design. The Ease of Communication Scale (ECS) measured patients' communication difficulty, and care processes measured the program's success. Study Population: Nurses (N 5 385) across 5 intensive care units were trained in SPEACS-2. We assessed 354 nonvocal patients (aged 18-95 years) requiring continued mechanical ventilation after withdrawal of heavy sedation. Patients were evaluated over one 2-week preintervention (n5163) and two 3-week postintervention periods (n5128; n563). A subsample of intervention patients (n 5 204) completed the ECS. Results: Ease of Communication Scale scores improved significantly (p 5 .027) from baseline (mean 25.86 6 12.2, n 5 71) to postintervention period 2 (21.22 6 12.2, n 5 63). Nurses' use of communication techniques and compliance with communication plans of care incrementally increased after training. Conclusions: Implementing SPEACS-2 demonstrated positive changes in patients' ease of communication and feasibility of incorporating evidence-based communication strategies into practice. [ABSTRACT FROM AUTHOR]

Purpose: To recruit healthy full- and preterm infants into genetic research and determine the effectiveness of a noninvasive DNA sampling technique for comparing epigenetic modifications. Background: Noxious stimuli during a vulnerable period of infant neuronal plasticity may trigger long-term epigenetic changes affecting neurodevelopment, pain modulation, and reactivity. Recognizing epigenetic pain findings is problematic because parents are reluctant to enroll newborns into genetic research. Methods: Design: Within-subject change over time candidate-gene DNA methylation association study. Setting/sample: Urban teaching hospital’s neonatal intensive care unit and newborn nursery. Convenience sample of healthy full- (>37 weeks, n = 6) and preterm (<37 weeks, n = 6) infants. Procedure: Parents participated in a genetic presentation prior to informed consent. Infant buccal saliva was collected after admission to the unit and prior to discharge. Analysis: The methylation pattern at the 5′ end of µ-opioid receptor gene (OPRM1) was examined. DNA was treated with bisulfite to convert all cytosines to uracil residues, leaving methylated cytosines unchanged. Sequencing of untreated and bisulfite-converted DNA was carried out. The sequences of unconverted and bisulfite-converted DNA were aligned with ClustalW, fidelity of the polymerase chain reaction and the sequencing reaction evaluated, and the methylation pattern identified. Results: Recruitment and assessment of a noninvasive DNA sampling technique for comparing epigenetic modifications were successful; however, infant stress did not produce a change in OPRM1 methylation expression. Relevance: This study established the feasibility of recruiting healthy full-term infants into genetic research and the effectiveness of noninvasive DNA sampling for comparing epigenetic modification in infants. [ABSTRACT FROM AUTHOR]

Objective. To develop consensus recommendations on urine drug monitoring (UDM) in patients with chronic pain who are prescribed opioids. Methods. An interdisciplinary group of clinicians with expertise in pain, substance use disorders, and primary care conducted virtual meetings to review relevant literature and existing guidelines and share their clinical experience in UDM before reaching consensus recommendations. Results. Definitive (e.g., chromatography-based) testing is recommended as most clinically appropriate for UDM because of its accuracy; however, institutional or payer policies may require initial use of presumptive testing (i.e., immunoassay). The rational choice of substances to analyze for UDM involves considerations that are specific to each patient and related to illicit drug availability. Appropriate opioid risk stratification is based on patient history (especially psychiatric conditions or history of opioid or substance use disorder), prescription drug monitoring program data, results from validated risk assessment tools, and previous UDM. Urine drug monitoring is suggested to be performed at baseline for most patients prescribed opioids for chronic pain and at least annually for those at low risk, two or more times per year for those at moderate risk, and three or more times per year for those at high risk. Additional UDM should be performed as needed on the basis of clinical judgment. Conclusions. Although evidence on the efficacy of UDM in preventing opioid use disorder, overdose, and diversion is limited, UDM is recommended by the panel as part of ongoing comprehensive risk monitoring in patients prescribed opioids for chronic pain. [ABSTRACT FROM AUTHOR]

Objective. The Defense and Veterans Pain Rating Scale (DVPRS 2.0) is a pain assessment tool that utilizes a numerical rating scale enhanced by functional word descriptors, color coding, and pictorial facial expressions matched to pain levels. Four supplemental questions measure how much pain interferes with usual activity and sleep, and affects mood and contributes to stress. Methods. Psychometric testing was performed on a revised DVPRS 2.0 using data from 307 active duty service members and Veterans experiencing acute or chronic pain. A new set of facial representations designating pain levels was tested. Results. Results demonstrated acceptable internal consistency reliability (Cronbach's alpha = 0.871) and test-retest reliability (r = 0.637 to r = 0.774) for the five items. Excellent interrater agreement was established for correctly ordering faces depicting pain levels and aligning them on the pain intensity scale (Kendall's coefficient of concordance, = 5 0.95 and 0.959, respectively). Construct validity was supported by an exploratory principal component factor analysis and known groups validity testing. Most participants, 70.9%, felt that the DVPRS was superior to other pain rating scales. Consclusion. The DVPRS 2.0 is a reliable and valid instrument that provides standard language and metrics to communicate pain and related outcomes. [ABSTRACT FROM AUTHOR]

To forge strong relationships among nurse scholars from the University of Pennsylvania School of Nursing, Philadelphia, PA ( USA); University of Botswana School of Nursing, Gaborone, Botswana; the Hospital of the University of Pennsylvania, Philadelphia; Princess Marina Hospital ( PMH), Gaborone; and the Ministry of Health of Botswana, a strategic global partnership was created to bridge nursing practice and education. This partnership focused on changing practice at PMH through the translation of new knowledge and evidence-based practice. Guided by the National Institutes of Health team science field guide, the conceptual implementation of this highly successful practice change initiative is described in detail, highlighting our strategies, challenges and continued collaboration for nurses to be leaders in improving health in Botswana. [ABSTRACT FROM AUTHOR]

Background Consensus indicates that a comprehensive, multimodal, holistic approach is foundational to the practice of acute pain medicine (APM), but lack of uniform, evidence-based clinical pathways leads to undesirable variability throughout U. S. healthcare systems. Acute pain studies are inconsistently synthesized to guide educational programs. Advanced practice techniques involving regional anesthesia assume the presence of a physician-led, multidisciplinary acute pain service, which is often unavailable or inconsistently applied. This heterogeneity of educational and organizational standards may result in unnecessary patient pain and escalation of healthcare costs. Methods A multidisciplinary panel was nominated through the APM Shared Interest Group of the American Academy of Pain Medicine. The panel met in Chicago, IL, in July 2014, to identify gaps and set priorities in APM research and education. Results The panel identified three areas of critical need: 1) an open-source acute pain data registry and clinical support tool to inform clinical decision making and resource allocation and to enhance research efforts; 2) a strong professional APM identity as an accredited subspecialty; and 3) educational goals targeted toward third-party payers, hospital administrators, and other key stakeholders to convey the importance of APM. Conclusion This report is the first step in a 3-year initiative aimed at creating conditions and incentives for the optimal provision of APM services to facilitate and enhance the quality of patient recovery after surgery, illness, or trauma. The ultimate goal is to reduce the conversion of acute pain to the debilitating disease of chronic pain. [ABSTRACT FROM AUTHOR]

Objective. Examine response patterns to low-dose intravenous ( IV) ketamine continuous infusions on multiple pain outcomes, and demonstrate effectiveness, safety, and tolerability of ketamine administration on general wards. Design. Retrospective case series of consecutive patients given low-dose IV ketamine continuous infusions. Setting. Walter Reed Army Medical Center, Washington, DC. Patients. Nineteen eligible inpatients with neuropathic pain from major limb injuries sustained in combat with inadequate pain control from multimodal analgesia. Interventions. A 3-day IV infusion of ketamine at doses ≤120 μg/kg/h. Outcome Measures. Daily present ( PPI), average ( API), and worst ( WPI) pain intensity (0-10), global pain relief ( GPR) (1 'no relief' to 5 'complete relief'), daily assessments of adverse events, and daily opioid requirements measured during therapy. Results. A significant reduction in PPI ( P < 0.001) and improvement in GPR ( P = 0.031) was noted over time. Higher baseline WPI (≥7; N = 14) was associated with a significant decrease in WPI ( P = 0.0388), but lower baseline WPI (N = 5) was not. Significant mean percent decreases in PPI with higher baseline PPI (N = 8; P = 0.0078) and WPI with no phantom limb pain ( PLP) (N = 10; P = 0.0436) were observed. Mean percent increase in overall GPR was better for those reporting GPR scores ≤3 (N = 13) in the first 24 hours of therapy ( P = 0.0153). While not significant, mean opioid requirement ( IV morphine equivalents) decreased from 129.9 mgs ± 137.3 on day 1 to 112.14 ± 86.3 24 hours after therapy. Conclusions. Low-dose ketamine infusions for complex combat injury pain were safe and effective, and demonstrated response patterns over time and by baseline pain score stratification and presence or absence of PLP. [ABSTRACT FROM AUTHOR]

Background. The Army Surgeon General released the Pain Management Task Force final report in May 2010. Among military providers, concerns were raised that the standard numeric rating scale ( NRS) for pain was inconsistently administered and of questionable clinical value. In response, the Defense and Veterans Pain Rating Scale ( DVPRS) was developed. Methods. The instrument design integrates pain rating scale features to improve interpretability of incremental pain intensity levels, and to improve communication and documentation across all transitions of care. A convenience sample of 350 inpatient and outpatient active duty or retired military service members participated in the study at Walter Reed Army Medical Center. Participants completed the five-item DVPRS-one pain intensity NRS with and without word descriptors presented in random order and four supplemental items measuring general activity, sleep, mood, and level of stress and the Brief Pain Inventory seven interference items. Using systematic sampling, a random sample was selected for a word descriptor validation procedure matching word phases to corresponding pain intensity on the NRS. Results. Parallel forms reliability and concurrent validity testing demonstrated a robust correlation. When the DVPRS was presented with the word descriptors first, the correlation between the two ratings was slightly higher, r = 0.929 ( N = 171; P < 0.001), than ordering first without the descriptors, r = 0.882 ( N = 177; P < 0.001). Intraclass correlation coefficient was 0.943 showing excellent alignment of word descriptors by respondents ( N = 42), matching them correctly with pain level. Conclusions. The DVPRS tool demonstrated acceptable psychometric properties in a military population. [ABSTRACT FROM AUTHOR]

Background. Few studies demonstrate the impact of early aggressive analgesia with acute pain service (APS) involvement at combat support hospitals (CSHs) using real-time data. Collaboration between the British and the United States (US) Army led to a 3-month deployment of a US Army APS to Camp Bastion, the main British military base in southern Afghanistan, from April to July 2009. Methods. Pain outcomes data were collected at Camp Bastion from 71 soldiers sustaining major combat injuries followed by an APS. Results. The sample was predominantly male (98.6%) and Caucasian (98.8%) with a mean age 25.4 years ± 5.4 (range 18-45). Regional nerve blocks were performed in 51 (71.8%) and epidurals placed in 11 (15.5%) of the cases. Repeated measures analysis of variance showed a statistically significant decreases in pain intensity (numeric rating scale from 0 for 'none' to 10 for 'as bad as you can imagine') over the three data collection points; first 3, 4-6, and 7-10 hours ( F = 133.35; degrees of freedom [df; 1,68]; P < 0.001). Mean percent pain relief (0% 'no relief' to 100% 'complete relief') increased significantly over time ( F = 193.12; df[1,69]; P < 0.001) with scores 31.29% ± 20.3 (initial 3 hours), 74.86% ± 27.5 (4-6 hours), and 83.14% ± 19.3 (7-24 hours). Overall, the perceived quality of pain control by soldiers was high. Conclusions. Findings from this quality of pain care study show that aggressive multimodal analgesia interventions by an APS in a CSH is associated with decreased pain intensity and increased pain relief. [ABSTRACT FROM AUTHOR]

Objective. The primary goal of this investigation was to survey military health care professionals at a Camp Bastion, Afghanistan, regarding their perceptions of care delivered by an anesthesiologist-directed acute pain service (APS) at a British Combat Support Hospital (CSH)-Role 3. Methods. The APS was directed by a U.S. Army anesthesiologist experienced in acute pain medicine who established an APS within a deployed British CSH. A brief 15-item survey was developed to assess impressions of outcomes, complexity of care, and satisfaction with the APS. Content validity was established through limited published surveys of APSs, expert review, and end user evaluation. Results. The sample (N = 70, of which 61.4% were male) included 50% nurses, 15.8% surgeons, and 10% anesthesiologists who completed the survey at the end of the 3-month APS implementation period. Approximately 75% of the sample agreed or strongly agreed that injured soldiers managed by an APS obtained better pain relief than those who were not. With a 10-point scale, respondents rated how satisfied they were with the APS (mean 7.70 ± 1.7), how beneficial it was for patients (7.89 ± 2), and how important it would be to deploy an APS again to a level 3 facility (8.52 ± 1.7). Internal consistency reliability (Cronbach's alpha) for the 12-items measuring perceptions was acceptable, alpha = 0.82. Conclusions. Overall, the majority of military health care survey responders indicated support for an APS team as part of a CSH care, and confirmed its contributions to improving trauma care. [ABSTRACT FROM AUTHOR]

Background. Pain is strongly associated with significant personal and societal costs. A crucial element of any initiative on pain must focus on eliminating pain care disparities that are pervasive throughout the United States health care settings. Objectives. This report focuses on macro-level factors related to pain care disparities in the United States that may be amenable to policy interventions. Methods. We identify concrete opportunities for achieving equity in pain care, especially those occasioned by recent legislative changes in the United States health care system. An aggressive policy, advocacy, and research agenda is synthesized in five domains: 1) structural/system; 2) policy and advocacy; 3) workforce; 4) provider; and 5) research. Results. Inequities in pain care remain an important and neglected health policy concern. Many direct and indirect provisions within the Affordable Care Act (ACA) and other national initiatives that leverage on ACA offer opportunities to achieve equity in pain care. These include changes in insurance, in public, provider, and legislative education, in primary care and pain specialist training, improving workforce diversity, achieving uniformity in race/ethnicity data collection, emphasizing patient-centered outcomes research, and encouraging focus on pain care disparities within the comparative effectiveness research paradigm. Conclusions. Recent national legislative initiatives within ACA are expected to generate multilevel efforts that will impact the flow of funding to address the pervasive issue of disparities. It is an opportune time for the pain community to take a lead in implementing a concerted agenda on pain care disparities in order to leverage these national initiatives. [ABSTRACT FROM AUTHOR]

Abbreviation use is a preventable cause of medication errors. The objective of this study was to test whether computerized alerts designed to reduce medication abbreviations and embedded within an electronic progress note program could reduce these abbreviations in the non-computer-assisted handwritten notes of physicians. Fifty-nine physicians were randomized to one of three groups: a forced correction alert group; an auto-correction alert group; or a group that received no alerts. Over time, physicians in all groups significantly reduced their use of these abbreviations in their handwritten notes. Physicians exposed to the forced correction alert showed the greatest reductions in use when compared to controls (p=0.02) and the auto-correction alert group (p=0.0005). Knowledge of unapproved abbreviations was measured before and after the intervention and did not improve (p=0.81). This work demonstrates the effects that alert systems can have on physician behavior in a non-computerized environment and in the absence of knowledge. [ABSTRACT FROM AUTHOR]

Evidence shows that disparities in pain care exist, and this problem spans across all health care settings. Health care disparities are complex, and stem from the health system climate, limitations imposed by laws and regulations, and discriminatory practices that are deep seated in biases, stereotypes, and uncertainties surrounding communication and decision-making processes. A search of the Internet identified thousands of Web sites, documents, reports, and educational materials pertaining to health and pain disparities .Web sites for federal agencies, private foundations, and professional and consumer-oriented organizations provide useful information on disparities related to age, race, ethnicity, geography, socioeconomic status, and specific populations. The contents of 10 Web sites are examined for resources to assist health professionals and consumers in better understanding health and pain disparities and ways to overcome them in practice. [ABSTRACT FROM AUTHOR]

Obesity is a significant, and increasing, health problem for older individuals, their caregivers, and healthcare professionals and delivery systems, yet few studies document how nursing homes have responded to this epidemic. To address these gaps, an extensive electronic search was conducted in the Cumulative Index of Nursing and Allied Health, MedLine, PubMed, and the Cochrane Library using key terms and phrases, including obesity, morbid obesity, obesity in elderly, long-term care, bariatric or weight loss surgery, nursing care, and nursing homes. Subsequent critical review suggests that research on obesity in older adults has predominantly been conducted in community-dwelling populations and that few investigations have elucidated this problem in nursing home (NH) residents. Research priorities are also proposed to fill the current void in studies of obese NH residents. [ABSTRACT FROM AUTHOR]

The authors performed an electronic search of websites that address psychosocial issues in pain management identified over 5 million sites. A search limited to pychosocial issues in pain produced nearly 400,000. Nine scientific, professional and consumer-oriented websites were selected for review of social support information and opportunities using criteria focusing on patient information, referrals for counseling services and community-based assistance programs, sell-help groups, specific pain syndromes, and readability and interpretability of consumer-oriented content. The internet can empower patients to self-manage their pain and seek out effective social support venues for improving their lives. [ABSTRACT FROM AUTHOR]

As the average life span of Americans increases, there is a tremendous need for geriatric-specific information and resources, especially for those older adults with life-limiting illnesses. Emerging literature underscores the differences in palliative and end-of-life approaches between younger and older adults in treating symptoms, understanding issues related to psychosocial and spiritual well-being, and alleviating caregiver burden. Hundreds of internet sites currently exist that pertain to geriatrics, and health professionals now have access to evidence-based clinical care guidelines, guides for education and training, and networks to support patients and their families. Even consumer-oriented organizations have assumed responsibility for informing patients and families and outlining supportive care services for patients and families. This paper reports the results of a systematic evaluation and critique of 15 websites, and summarizes their unique contributions clinical care guidelines, teaching materials and training opportunities, effective models of care, and advice on dealing with the complex emotional, social and financial issues facing older adults at the end-of-life. [ABSTRACT FROM AUTHOR]

End-of-life decisions regarding nutrition should be formed in light of available scientific information and socio-culturally sensitive aspects of patient/family centered care. An extensive internet search was performed to identify available resources concerning nutrition at the end of life and guide health professionals and consumers in the interpretation and clinical application of information. The results of this search yielded several internet sites that post content that can be useful to clinicians, consumers and both. The amount of accessible information on the World Wide Web is so extensive that considerable effort is required to appraise the accuracy and scientific value of subject matter while balancing patients and families perceived importance of nourishment during the end stages of life. Therefore, Internet-based information on nutrition at the end of life is presented and evaluated for the relative contributions that this type of information offers to clinicians, patients, and families. [ABSTRACT FROM AUTHOR]