Table 3

Management of Pain and Suffering

Relief of Pain and Suffering

In order to relieve pain and suffering at the end-of-life, both pharmacological and non-pharmacological means should be used. Non-pharmacological interventions include ensuring the presence of family, friends and pastoral care (if desired), and, changing the technological ICU environment to a more private and peaceful one. Nursing interventions and accommodating patients' religious and cultural beliefs also play an important role in alleviating pain and suffering. Pharmacological interventions include any analgesics, sedatives or other adjuncts that will decrease discomfort. In general, narcotics are used for pain; benzodiazepines are used for agitation and anxiety. If the patient is experiencing pain and suffering, both analgesics and sedatives are used. This combination of drugs may provide better relief of pain and suffering at the end-of-life than either class of drug alone.

Initial Dosage

Most ICU patients require narcotics and sedatives in order to ease the pain and suffering associated with their critical illness. The amount of drugs needed varies on an individual basis. As in active disease treatment, palliative care MUST be individualized. Considerations affecting the initial dose of narcotics and sedatives in palliation include: 1) the patient's previous narcotic exposure since tolerance develops quickly, 2) age, 3) previous alcohol or drug use and/or abuse, 4) underlying illness, 5) underlying organ dysfunction 6) the patient's current level of consciousness/ sedation, 7) level of available psychological/spiritual support, and, 8) patients' wishes regarding sedation.

Titration of Analgesics and Sedatives

Once analgesics and sedatives are initiated, they are increased in response to 1) patient's request, 2) signs of respiratory distress, 3) physiological signs: unexplained tachycardia, hypertension, diaphoresis, 4) facial grimacing, tearing, vocalizations with movements, turns or other nursing care, and 5) restlessness. These clinical indicators, although crucial for graduated therapy, are imprecise. Ramsay or Likert scales, despite their limitations, may provide additional help in evaluating the patient's discomfort. The total amount of drugs required for any individual patient may far exceed any preconceived notions of usual, in reality non-existent, doses.

Does a Maximal Dose Exist?

No maximum dose of narcotics or sedatives exist. The goal of palliative care is to provide relief of pain and suffering and whatever the amount of drugs that accomplishes this goal is the amount that is needed for that individual patient. By refusing to define a maximal dose of analgesics or sedatives, our goal is to ensure that Intensivists will use the required dose for each patient. If a maximal dose is ever declared, some patients will be in pain and will be suffering at the end-of-life because of the Intensivist's fears of litigation if this maximal dose is exceeded. Therefore, the intent of the physician administering the drugs becomes important in distinguishing between palliative care and assisted death (euthanasia/assisted suicide).

Should Analgesics and Sedatives be Administered in Response to Signs and Symptoms of Pain and Suffering, or Before They Begin?

Support for both approaches exists among Intensivists on this panel. The treatment of signs and symptoms of pain and suffering is good palliative care. When appropriate doses of narcotics and sedatives are used and the intent of the physician is clear and well documented, pre-emptive dosing in anticipation of pain and suffering is not euthanasia nor assisted suicide but good palliative care.

Hawryluck et al. BMC Medical Ethics 2002 3:3   doi:10.1186/1472-6939-3-3

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