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Background: Prognostication is an important element of palliative care consultations. Research has shown that estimated survivals offered by clinicians are often inaccurate; however, few of these studies have focused on the documentation and prognostic accuracy of palliative care providers., Objective: Our aim was to determine whether palliative care clinicians document specific estimates of survival in the electronic medical record and whether these survival estimates are accurate., Methods: We retrospectively analyzed 400 consecutive, new palliative care consults at an urban, academic medical center from October 1, 2009 to December 31, 2010. Descriptive statistics were used to summarize patient demographics, median patient survival, documented estimated survival, agreement between estimated and actual survival, and agreement differences among disease groups., Results: The inpatient consult note template was utilized by the clinicians in 94.2% of the patients analyzed, and 69.4% of the patients analyzed had a specific survival estimate documented. Of the patients with specific survival estimates documented, 42.6% died in the time frame estimated. Weighted kappa coefficients and Kaplan survival estimators showed fair to moderate agreement between actual survival and estimated survival offered by palliative care clinicians. Survival groups with the shortest prognosis had the most accurate estimates of prognosis. Cancer had the least agreement between estimated and actual survival among disease types. Overestimation of survival was the most common prognostic error. Use of a template resulted in significantly greater documentation of a specific estimated survival., Conclusions: The prognostic accuracy of palliative care physicians in this study was similar to physician accuracy in other studies. Trends toward overestimation were also similar to those seen in previous research. Use of a template in the electronic medical record (EMR) increases documentation of estimated prognosis.

Many people with dementia are unable to clearly or consistently verbalize pain symptoms. The Assessment of Discomfort in Dementia (ADD) Protocol is a systematic tool that can be used by nurses to make a differential assessment and treatment plan for both physical pain and affective discomfort experienced by people with dementia. This ADD Protocol is based on the assumption that behaviors associated with dementia are symptoms of unmet physiologic and/or nonphysiologic needs. Steps of the process include a physical assessment, a review of the patient's history, an assessment of affective needs including environmental stress and sensoristasis, and the administration of analgesics. The ADD Protocol is unique in that it uses "as needed" analgesics as a part of the assessment process. The dualistic perspective, in which physical and affective needs are considered in tandem, is an essential and innovative feature of the ADD Protocol.

The Assessment of Discomfort in Dementia (ADD) Protocol was developed to improve recognition and treatment of physical pain and affective discomfort in people with dementia who are no longer able to clearly or consistently report on their internal states. The purpose of this study was to describe use of each step of the ADD protocol with 143 residents of long-term care facilities. Of the subjects who received nonpharmacological comfort interventions, 37% showed improved symptoms. Of the 91 protocols in which an analgesic was administered, 83.5% showed improved symptoms. People who complained verbally received considerably more analgesics and other comfort interventions. Limitations inherent in this descriptive exploratory study do not permit conclusions regarding the effectiveness of the ADD protocol. Research with a control group, random assignment, and objective measures of discomfort level is planned., (Copyright 2001 by W.B. Saunders Company)

Among the knowledge required by healthcare professionals to manage pain is an understanding of the differences between opioid agents and formulations. As the list of new opioid formulations continues to grow, it is increasingly important that clinicians understand the basic pharmacology of these analgesics and how to calculate equianalgesic doses. Administering an equianalgesic dose increases the likelihood that the transition to another opioid or route will be tolerated without loss of pain control or excessive side effects. Although calculation of equianalgesic doses requires relatively simple mathematical skills, few clinicians are prepared to compute them. The purpose of this article is to provide a basic review of the pharmacology of opioids, explain how to calculate an equianalgesic dose, and briefly describe some of the current controversies of the relative potencies of opioids listed in equianalgesic tables.

Education of health care providers has historically been based on the traditional model of curative care. In this model, the curative care focus suddenly ends, substituted by a palliative approach to care, too often only in the last hours of life. Patient goals and wishes may never be clearly established, leaving family and care providers to guess at what the patient's wishes were. If we are to provide quality palliative care, we must equate it with health care providers establishing, acknowledging, and honoring patient and family goals. A major facilitator in accomplishing palliative care goals can arise from the nursing assessment. This article reviews the elements of a comprehensive nursing palliative care assessment (PCA). Although this article focuses on nurses, it has application for all health care professionals. Completion of the PCA provides an opportunity for reflection and evaluation of personal practices that support integrating palliative care into the care of all patients diagnosed with a life-threatening illness, beginning at the time of diagnosis and accelerating in intensity as the disease progresses.