In some developed countries, approximately one in five people die in the Intensive Care Unit (ICU), and Palliative Care (PC) has become an increasingly practice in this setting. Approximately 40% of patients with a high probability of death, and over 50% of the patients who are admitted to the ICU, experience moderate to severe pain during their hospital stay. Furthermore, the complexity of disease in elderly patients is leading to increased mortality from chronic illness in the critical care environment.
This situation highlights that high-quality PC for the critically ill is imperative and is currently at the forefront of quality improvement agendas for ICUs.

Despite the priority of this issue, studies have shown that compliance with appropriate pain management during PC in the ICU is only present in 80% of cases. Also, caregivers' satisfaction with the quality of pain control of their loved ones is variable; ranging from 47% to 86.9%.

A systematic review and quality assessment of clinical practice guidelines and consensus statements from scientific societies and experts summarizes the guidelines and recommendations of pain management at the end-of-life in the ICU. They propose that a proper understanding of the entire process — from pain assessment to pain management, available interventions, and multidisciplinary collaboration — is fundamental for achieving adequate pain control.

Recommendations about:
• Pain assessment. Use a systematic method for patient evaluation. Any systematic form of ongoing pain assessment implementable by ICU staff may be sufficient.
• Pain management interventions. Use opioids and benzodiazepines for symptom relief. Bolus and infusions are recommended, depending on the status of the patient and the availability of IV access, with the alternative of using subcutaneous medications if IV access is not available, or oral medications if the patient can swallow.
• Titration. It is imperative to titrate-up dosages until pain and suffering are relieved, without exceeding maximum dosage. Starting dosages should be adjusted individually depending on patient characteristics and clinical conditions. Using the drug the intensivist is most familiar with is good practice.
• Nonpharmacologic interventions. These are also necessary for the adequate management of dying patients.
• Adjuvant medications. These are essential for the prevention or identification of side effects associated with opioids. Adjuvant medications should be ready to be administered in the event that side effects are suspected.
• The presence of family, friends, and spiritual care. If desired, this should be offered and secured, as well as the avoidance of any intervention that may cause pain or suffering.
• The principle of double effect. This is fundamental in justifying the use of high doses of narcotic and sedative medication at the end of life. The clinician's use of medications for symptom management should be explained by adequate communication. Intensivists must bear in mind the legal implications of exceeding the maximum dosages of medications needed for symptom control, according to their local legislation.

Critical care practitioners should develop a routine collaboration with PC specialists so that timely intervention can be available for the patient and their family as soon as indicated. PC consultation should be required promptly when the limits of the critical care specialist's experience have been reached.
A consult with PC may bring benefits: ensuring that all possible interventions have been performed, improving communication between ICU staff and the patient's family, and educating providers about PC initiatives in the care of dying patients.

See reference for more information, and to see the pain management algorithm for critically ill patients at the end-of-life.

Adapted from Medscape News & Perspective. Clinical practice guidelines and consensus statements about pain management in critically ill end-of-life patients. Internet. Available at https://www.medscape.com/viewarticle/920024?src=wnl_edit_tpal&uac=6705FY&impID=2150589&faf=1 Accessed on January 25, 2020. To view the entire article and all other content on the Medscape News and Perspective site, a