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Background: The epidemiology of pain during the last years of life has not been well described. Objective: To describe the prevalence and correlates of pain during the last 2 years of life. Design: Observational study. Data from participants who died while enrolled in the Health and Retirement Study were analyzed. The survey interview closest to death was used. Each participant or proxy was interviewed once in the last 24 months of life and was classified into 1 of 24 cohorts on the basis of the number of months between the interview and death. The relationship between time before death and pain was modeled and was adjusted for age, sex, race or ethnicity, education level, net worth, income, terminal diagnosis category, presence of arthritis, and proxy status. Setting: The Health and Retirement Study, a nationally representative survey of community-living older adults (1994 to 2006). Participants: Older adult decedents. Measurements: Clinically significant pain, as indicated by a report that the participant was 'often troubled' by pain of at least moderate severity. Results: The sample included 4703 decedents. Mean age (SD) of participants was 75.7 years (SD, 10.8); 83.1% were white, 10.7% were black, 4.7% were Hispanic; and 52.3% were men. The adjusted prevalence of pain 24 months before death was 26% (95% CI, 23% to 30%). The prevalence remained flat until 4 months before death (28% [CI, 25% to 32%]), then it increased, reaching 46% (CI, 38% to 55%) in the last month of life. The prevalence of pain in the last month of life was 60% among patients with arthritis versus 26% among patients without arthritis (P < 0.001) and did not differ by terminal diagnosis category (cancer [45%], heart disease [48%], frailty [50%], sudden death [42%], or other causes [47%]; P = 0.195). Limitation: Data are cross-sectional; 19% of responses were from proxies; and information about cause, location, and treatment of pain was not available. Conclusion: Although the prevalence of pain increases in the last 4 months of life, pain is present in more than one quarter of elderly persons during the last 2 years of life. Arthritis is strongly associated with pain at the end of life. Primary Funding Source: National Institute on Aging, National Center for Research Resources, National Institute on Musculoskeletal and Skin Diseases, and National Palliative Care Research Center.

The purpose of this study was to describe nurses&apos; perceptions of their practices in the assessment and management of pain in children. Questionnaires were distributed to 260 nurses in a pediatric hospital in the western United States. Results showed that nurses are not consistently assessing pain in children, and pain management practices are not based on systematic assessment. The most frequently reported tool for assessing pain was the numeric rating scale. Children experience a variety of painful procedures during hospitalization, but nurses reported that they are not consistently administering analgesics for painful procedures. Although rarely used, distraction and relaxation techniques were the most frequently reported nonpharmacological interventions. Although nurses did not feel that there were factors preventing them from assessing or managing pain in children, their practices revealed both that they are not using developmentally appropriate tools for assessing pain, and they have not maximized the use of management strategies for controlling pain., The literature on pain assessment and management in children had increased considerably in the last 20 years. However, knowledge from this research has not been widely applied in practice. Pain [...]

The evidence shows that brain-injured patients express behaviours that are related to their level of consciousness (LOC), and different from other patients in the intensive care unit (ICU). Therefore, existing behavioural scales should be revised to enhance their content and validity for use in these patients.

Rapid response teams (RRTs) can effectively foster discussions about appropriate goals of care and address other emergent palliative care needs of patients and families facing life-threatening illness on hospital wards. In this article, The Improving Palliative Care in the ICU (IPAL-ICU) Project brings together interdisciplinary expertise and existing data to address the following: special challenges for providing palliative care in the rapid response setting, knowledge and skills needed by RRTs for delivery of high-quality palliative care, and strategies for improving the integration of palliative care with rapid response critical care. We discuss key components of communication with patients, families, and primary clinicians to develop a goal-directed treatment approach during a rapid response event. We also highlight the need for RRT expertise to initiate symptom relief. Strategies including specific clinician training and system initiatives are then recommended for RRT care improvement. We conclude by suggesting that as evaluation of their impact on other outcomes continues, performance by RRTs in meeting palliative care needs of patients and families should also be measured and improved.

The diagnosis of breast cancer, in combination with the anticipation of surgery, evokes fear, uncertainty, and anxiety in most women.

This review highlights benefits that patients, families and clinicians can expect to realize when palliative care is intentionally incorporated into the PICU.

Patients with advanced illness often spend time in an ICU, while nearly one-third of patients with advanced cancer who receive Medicare die in hospitals, often with failed ICU care. For most, death occurs following the withdrawal or withholding of life-sustaining treatments. The integration of palliative care is essential for high-quality critical care. Although palliative care specialists are becoming increasingly available, intensivists and other physicians are also expected to provide basic palliative care, including symptom treatment and communication about goals of care. Patients who are critically ill are often unable to make decisions about their care. In these situations, physicians must meet with family members or other surrogates to determine appropriate medical treatments. These meetings require clinical expertise to ensure that patient values are explored for medical decision making about therapeutic options, including palliative care. Meetings with families take time. Issues related to the disease process, prognosis, and treatment plan are complex, and decisions about the use or limitation of intensive care therapies have life-or-death implications. Inadequate reimbursement for physician services may be a barrier to the optimal delivery of high-quality palliative care, including effective communication. Appropriate documentation of time spent integrating palliative and critical care for patients who are critically ill can be consistent with the Current Procedural Terminologycodes (99291 and 99292) for critical care services. The purpose of this article is to help intensivists and other providers understand the circumstances in which integration of palliative and critical care meets the definition of critical care services for billing purposes.

Blunt thoracic injury (BTI) in older adults can lead to grave illness, permanent disability, and even death. Using Haddon’s phase-factor matrix model, this article examines the phenomenon of BTI in older adults. Preventive, diagnostic, and treatment interventions are discussed from the perspective of the pre-event, event, and post-event phases. Relevant physiological and pathophysiological changes regarding senescence and injury are reviewed, as are the common mechanisms of blunt trauma and anatomic injury patterns seen in older adults. Considerations for clinical interventions and future research are also presented.

We have come to appreciate that pain is more prevalent in patients than commonly believed 20 years ago. Unfortunately, in acute and critical care areas, pain is routinely inflicted as part of diagnostic or treatment-related activities. To provide data to guide pain management practice in the ICU, the American Association of Critical-Care Nurses undertook a large multi-site research project designed to describe the pain perceptions and experiences associated with several commonly performed procedures in the acute and critical care setting. The study was implemented at 169 sites across the United States and in Canada, Australia, and the United Kingdom. Six commonly performed procedures were studied, and over 6,000 patients participated in the study.

Procedural pain has been underestimated and understudied in critically ill patients. Despite the frequency with which critical care patients undergo procedures, little is known about the degree of associated pain and the effectiveness of interventions. This article presents research findings that should help nurses to provide evidence-based interventions to adult patients experiencing surgical and procedural pain in the critical care setting. In addition, the significance and underlying mechanisms of surgical and procedural pain are discussed.

Objective:To determine whether IM ketorolac is superior to oral ibuprofen in patients presenting to an ED in moderate to severe pain.

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