Palliative care in the ICU: relief of pain, dyspnea, and thirst—A report from the IPAL-ICU Advisory Board

• Published in: Intensive care medicine Vol. 40; no. 2; pp. 235 - 248
• Main Authors: Puntillo, Kathleen, Nelson, Judith Eve, Weissman, David, Curtis, Randall, Weiss, Stefanie, Frontera, Jennifer, Gabriel, Michelle, Hays, Ross, Lustbader, Dana, Mosenthal, Anne, Mulkerin, Colleen, Ray, Daniel, Bassett, Rick, Boss, Renee, Brasel, Karen, Campbell, Margaret
• Format: Journal Article
• Language: English
• Published: Berlin/Heidelberg Springer Berlin Heidelberg 01-02-2014; Springer; Springer Nature B.V
• Subjects: Anesthesiology; Care and treatment; Catheters; Critical care; Critical Care - standards; Critical Care Medicine; Dyspnea; Dyspnea - diagnosis; Dyspnea - therapy; Emergency Medicine; Evidence-based medicine; Hospital patients; Humans; Illnesses; Intensive; Intensive care; Intensive Care Units; Interdisciplinary aspects; Medicine; Medicine & Public Health; Narcotics; Opioids; Pain; Pain Management; Pain Measurement; Pain Medicine; Palliative Care; Palliative treatment; Patients; Pediatrics; Pneumology/Respiratory System; Quality Improvement; Review; Suctioning; Thirst; Ventilators; Palo Alto California; United States > US; San Francisco California; Pain; Dyspnea; Thirst; Palliation
• ISSN: 0342-4642; 1432-1238
• DOI: 10.1007/s00134-013-3153-z

Purpose
Pain, dyspnea, and thirst are three of the most prevalent, intense, and distressing symptoms of intensive care unit (ICU) patients. In this report, the interdisciplinary Advisory Board of the Improving Palliative Care in the ICU (IPAL-ICU) Project brings together expertise in both critical care and palliative care along with current information to address challenges in assessment and management.
Methods
We conducted a comprehensive review of literature focusing on intensive care and palliative care research related to palliation of pain, dyspnea, and thirst.
Results
Evidence-based methods to assess pain are the enlarged 0–10 Numeric Rating Scale (NRS) for ICU patients able to self-report and the Critical Care Pain Observation Tool or Behavior Pain Scale for patients who cannot report symptoms verbally or non-verbally. The Respiratory Distress Observation Scale is the only known behavioral scale for assessment of dyspnea, and thirst is evaluated by patient self-report using an 0–10 NRS. Opioids remain the mainstay for pain management, and all available intravenous opioids, when titrated to similar pain intensity end points, are equally effective. Dyspnea is treated (with or without invasive or noninvasive mechanical ventilation) by optimizing the underlying etiological condition, patient positioning and, sometimes, supplemental oxygen. Several oral interventions are recommended to alleviate thirst. Systematized improvement efforts addressing symptom management and assessment can be implemented in ICUs.
Conclusions
Relief of symptom distress is a key component of critical care for all ICU patients, regardless of condition or prognosis. Evidence-based approaches for assessment and treatment together with well-designed work systems can help ensure comfort and related favorable outcomes for the critically ill.