Challenge of assessing symptoms in seriously ill intensive care unit patients: can proxy reporters help?

Inter-rater agreement between patient- and proxy-reported cognitive functioning in intensive care unit patients: A cohort study

BACKGROUND

Health status, including cognitive functioning before critical illness, is associated with long-term outcomes in intensive care unit survivors. Premorbid data are therefore of importance in longitudinal studies. Few patients can self-report at intensive care admission. Consequently, proxy assessments of patients' health status are used. However, it remains unclear how accurately proxies can report on an intensive care patient's cognitive status.

OBJECTIVES

The aim of this study was to examine the agreement between patient- and proxy-reporting of the Cognitive Failures Questionnaire and to compare the agreement between proxy reports using the latter questionnaire and the Informant Questionnaire of Cognitive Decline in the Elderly as a reference.

METHODS

The present cohort study is part of a longitudinal multicentre study collecting both patient and proxy data using questionnaires and clinical data from medical records during intensive care unit stays. Agreement on patient and proxy pairs was examined using intraclass correlation coefficient (ICC), Spearman's correlation, percentage agreement, and Gwet's AC1 statistics. Agreement between the proxy-reported questionnaires was examined using percentage agreement and Gwet's AC1 statistics.

RESULTS

In total, we collected 99 pairs of patient-proxy assessments and 158 proxy-proxy assessments. The ICC for the sum scores revealed moderate agreement (n = 99; ICC = 0.59; 99% confidence interval [CI]: [0.30-0.76]) between patient and proxy. Agreement on items was poor (AC1 = 0.13; 99% CI: [0.01-0.24]) to moderate (AC1 = 0.55; 99% CI: [0.43-0.68]). Agreement using cut-off scores (>43) to indicate cognitive impairment was very good (89.9%, AC1 = 0.87; 99% CI: [0.79-0.95]). Agreement between the proxy-reported Cognitive Failures Questionnaire (>43) and the reference questionnaire (≥3.5) was also very good (n = 158; 85%, AC1 = 0.82; 99% CI: [0.74-0.90]).

CONCLUSIONS

Proxy assessments of the Cognitive Failures Questionnaire (>43) may be used to indicate cognitive impairment if patients are unable to self-report. Agreement was high between the two questionnaires determined by proxies, showing that these can be used interchangeably to assess cognitive functioning if proxy reporting is needed.

Easing Suffering for ICU Patients and Their Families: Evidence and Opportunities for Primary and Specialty Palliative Care in the ICU

Intensive care unit (ICU) admissions are often accompanied by many physical and existential pressure points that can be extraordinarily wearing on patients and their families and surrogate decision makers (SDMs). Multidisciplinary palliative support, including physicians, advanced practice nurses, nutritionists, chaplains and other team members, may alleviate many of these sources of potential suffering. However, the palliative needs of ICU patients undoubtedly exceed the bandwidth of current consultative specialty palliative medicine teams. Informed by standard-of-care palliative medicine domains, we review common ICU symptoms (pain, dyspnea and thirst) and their prevalence, sources and their treatment. We then identify palliative needs and impacts in the domains of communication, SDM support and transitions of care for patients and their families through their journey in the ICU, from discharge and recovery at home to chronic critical illness, post-ICU disability or death. Finally, we examine the evidence for strategies to incorporate specialty palliative medicine and palliative principles into ICU care for the improvement of patient- and family-centered care. While randomized controlled studies have failed to demonstrate measurable improvement in pre-determined outcomes for patient- and family-relevant outcomes, embracing the principles of palliative medicine and assuring their delivery in the ICU is likely to translate to overall improvement in humanistic, person-centered care that supports patients and their SDMs during and following critical illness.

Does Differential Item Functioning Jeopardize the Comparability of Health-Related Quality of Life Assessment Between Patients and Proxies in Patients with Moderate-to-Severe Traumatic Brain Injury?

BACKGROUND

Health-related quality of life (HRQoL) is clearly recognized as a patient-important outcome in patients with traumatic brain injury (TBI). Patient-reported outcomes are therefore often used and supposed to be directly reported by the patients without interpretation of their responses by a physician or anyone else. However, patients with TBI are often unable to self-report because of physical and/or cognitive impairments. Thus, proxy-reported measures, e.g., family members, are often used on the patient's behalf. Yet, many studies have reported that proxy and patient ratings differ and are noncomparable. However, most studies usually do not account for other potential confounding factors that may be associated with HRQoL. In addition, patients and proxies can interpret some items of the patient-reported outcomes differently. As a result, item responses may not only reflect patients' HRQoL but also the respondent's (patient or proxy) own perception of the items. This phenomenon, called differential item functioning (DIF), can lead to substantial differences between patient-reported and proxy-reported measures and compromise their comparability, leading to highly biased HRQoL estimates. Using data from the prospective multicenter continuous hyperosmolar therapy in traumatic brain-injured patients study (240 patients with HRQoL measured with the Short Form-36 (SF-36)), we assessed the comparability of patients' and proxies' reports by evaluating the extent to which items perception differs (i.e., DIF) between patients and proxies after controlling for potential confounders.

METHODS

Items at risk of DIF adjusting for confounders were examined on the items of the role physical and role emotional domains of the SF-36.

RESULTS

Differential item functioning was evidenced in three out of the four items of the role physical domain measuring role limitations due to physical health problems and in one out of the three items of the role emotional domain measuring role limitations due to personal or emotional problems. Overall, despite an expected similar level of role limitations between patients who were able to respond and those for whom proxies responded, proxies tend to give more pessimistic responses than patients in the case of major role limitations and more optimistic responses than patients in the case of minor limitations.

CONCLUSIONS

Patients with moderate-to-severe TBI and proxies seem to have different perceptions of the items measuring role limitations due to physical or emotional problems, questioning the comparability of patient and proxy data. Therefore, aggregating proxy and patient responses may bias HRQoL estimates and alter medical decision-making based on these patient-important outcomes.

Preliminary clinical testing to inform development of the Critical Care Pain Observation Tool for Families (CPOT-Fam)

Introduction

Many patients in the intensive care unit (ICU) cannot communicate. For these patients, family caregivers (family members/close friends) could assist in pain assessment. We previously adapted the Critical Care Pain Observation Tool (CPOT) for family caregiver use (CPOT-Fam). In this study, we conducted preliminary clinical evaluation of the CPOT-Fam to inform further tool development.

Methods

For preliminary testing, we collected (1) pain assessments of patients in the ICU from family caregivers (CPOT-Fam) and nurses (CPOT) and determined the degree of agreement (kappa coefficient, κ) and (2) collected openended feedback on the CPOT-Fam from family caregivers. For refinement, we used preliminary testing data to refine the CPOT-Fam with a multidisciplinary working group.

Results

We assessed agreement between family caregiver and nurse pain scores for 29 patients. Binary agreement (κ) between CPOT-Fam and CPOT item scores (scores ≥2 considered indicative of significant pain) was fair, κ = 0.43 (95% confidence interval [CI] 0.18-0.69). Agreement was highest for the CPOT-Fam items ventilator compliance/vocalization (weighted κ = 0.48, 95% CI 0.15-0.80) and lowest for muscle tension (weighted κ = 0.10, 95% [CI] -0.17 to 0.20). Most participants (n = 19; 69.0%) reported a very positive experience using the CPOT-Fam, describing it as "good" and "easy-to-use/clear/straightforward." We iteratively refined the CPOT-Fam over five cycles using the data collected until no further revisions were suggested.

Conclusion

Our preliminary clinical testing suggests that family involvement in pain assessment in the ICU is well perceived. The CPOT-Fam has been further refined and is now ready for clinical pilot testing to determine its feasibility and acceptability.

Nurses' assessment and management practices of pain among intensive care patients in King Khalid Hospital, Kharj, Riyadh

Background

Pain is a disagreeable combination of sensory and emotional sensations. Employing behavioral pain assessment tools is strongly associated with improved identification of pain.

Purpose

The main purpose of the study is to investigate Nurses' Assessment and Management Practices of Pain among Intensive Care Patients in King Khalid Hospital, Kharj, Riyadh.

Materials and methods

A self-administered questionnaire was employed in a descriptive cross-sectional study. The study focused on nurses employed in the intensive care unit at King Khalid Hospital in Al-Kharj Province. The researchers utilized convenience sampling to recruit participants. Out of the total 48 nurses approached 45 of them provided responses, leading to a response rate of 94%. The Critically Ill questionnaire was utilized to gather information regarding the treatment and evaluation of pain in patients who were in critical condition. Descriptive statistics and inferential statistics were employed to analyze the collected data.

Principal results

it was found that 88% of them utilized instruments to evaluate pain in patients who could express themselves. Among these instruments, the numeric rating scale was the most commonly employed. Furthermore, 77% of the nurses (35 in total) used a pain assessment tool for patients who were unable to communicate, with the Adult Nonverbal Pain Scale being the most frequently used tool in this case. The nurses' perception of the significance of pain assessment was positively associated with the regular utilization of pain assessment tools. Additionally, the nurses considered the use of pain assessment tools with patients who could communicate as more important compared to using such tools with patients who could not communicate.

Conclusions

Most ICU nurses utilized nurses' pain assessment instruments to assess the discomfort levels of both patients who could communicate and those who couldn't express themselves effectively. By employing such tools, nurses can improve patient outcomes, ensure effective pain management, and demonstrate a high standard of professional care.

Development and preclinical testing of the critical care pain observation tool for family caregiver use (CPOT-Fam)

Background and Aims

Pain assessment in noncommunicative intensive care unit (ICU) patients is challenging. For these patients, family caregivers (i.e., family members, friends) may be able to assist in pain assessment by identifying individualistic signs of pain due to their intimate patient knowledge. This study adapted the critical care pain observation tool (CPOT) to facilitate pain assessment in adult ICU patients by family caregivers.

Methods

This study was conducted through three distinct phases: (1)CPOT adaptation for family caregiver use (to create the CPOT-Fam): A working group met monthly to adapt the CPOT and develop educational material and sample cases for practice scoring until consensus was reached.(2)CPOT-Fam preclinical testing: Family caregiver study participants viewed educational materials and scored four randomly selected sample cases using the CPOT-Fam. Scores were compared to reference scores to assess agreement and identify CPOT-Fam sections requiring revision. Open-ended feedback on the CPOT-Fam was collected.(3)CPOT-Fam revision: the CPOT-Fam was revised by the working group considering score agreement and feedback received from study participants.

Results

Of the n = 30 participants, n = 14 (47.0%) had experience with an ICU patient. Agreement between CPOT-Fam participant scores and reference scores were highest for the vocalization dimension (Is the patient making any sounds?; Intraclass correlation coefficient; ICC = 1.0) and lowest for the body movements dimension (What are the patient's body movements like?; ICC = 0.85. Participants indicated they found the CPOT-Fam to be "informative" and "easy-to-use" but "not graphic enough"; participants also indicated that descriptors like "lack of breath" and "struggling to move" are helpful with identifying individualistic behaviors of pain exhibited by their loved ones.

Conclusion

The CPOT-Fam shows ease of use and may be of value in involving family caregivers in ICU care. Clinical pilot testing is needed to determine feasibility and acceptability and identify further areas for refinement.

Study protocol: development and pilot testing of the Critical Care Pain Observation Tool for families (CPOT-Fam)

Background

Patients in the intensive care unit (ICU) often have limited ability to communicate making it more difficult to identify and effectively treat their pain. Family caregivers or close friends of critically ill patients may be able to identify signs of pain before the clinical care team and could potentially assist in routine pain assessments. This study will adapt the Critical Care Pain Observation Tool (CPOT) for use by family members to create the CPOT-Fam and compare family CPOT-Fam assessments with nurse-provided CPOT assessments for a given patient.

Methods

This study will be executed in two phases:

1) Development of the CPOT-Fam — A working group of patient partners, ICU clinicians, and researchers will adapt the CPOT for use by family caregivers (creating the CPOT-Fam) and produce an accompanying educational module to deliver information on pain and how to use the tool. The CPOT-Fam will undergo preclinical testing with participants (i.e., members of the public and family caregivers of critically ill adults), who will complete the educational module and provide CPOT-Fam scores on sample cases. Feedback on the CPOT-Fam will be collected.

2) Pilot testing the CPOT — Fam family caregivers of critically ill adults will complete the educational module and provide information on the following: (1) demographics, (2) anxiety, (3) caregiving self-efficacy, and (4) satisfaction with care in the ICU. Family caregivers will then provide a proxy assessment of their critically ill loved one’s pain through the CPOT-Fam and also provide a subjective (i.e., questionnaire-based including open-ended responses) account of their loved one’s pain status. A comparison (i.e., agreement) will be made between family caregiver provided CPOT-Fam scores and ICU nurse-provided CPOT scores (collected from the provincial health information system), calculated independently and blinded to one another. Feasibility and acceptability of the CPOT-Fam will be determined.

Discussion

The results of this work will produce a family caregiver CPOT (i.e., CPOT-Fam), determine feasibility and acceptability of the CPOT-Fam, and compare pain assessments conducted by family caregivers and ICU nurses. The results will inform whether a larger study to determine a role for family caregivers in ICU pain assessment using the CPOT-Fam is warranted.

Supplementary Information

The online version contains supplementary material available at 10.1186/s40814-022-01102-3.

Acceptability and Feasibility of a Patient-Oriented Music Intervention to Reduce Pain in the Intensive Care: Protocol for a Randomized Crossover Pilot Trial (Preprint)

BACKGROUND

Many patients experience pain in the intensive care unit (ICU) despite receiving pain medication. Research has shown that music can help reduce pain. Music interventions studied so far have not used music streaming to generate playlists based on patient preferences while incorporating recommended tempo and duration. Previous research has focused on postoperative ICU patients able to self-report, which is underrepresentative of the ICU population that might benefit from a music intervention for pain management. We developed a new patient-oriented music intervention (POMI) that incorporates features based on theoretical, empirical, and experiential data intended to be used in the ICU. Such a music intervention should consider the expertise of ICU patients, family members, and nursing staff, as well as the practicality of the intervention when used in practice.

OBJECTIVE

The primary objectives of this study are to (1) evaluate the acceptability and feasibility of the POMI to reduce pain in ICU patients and (2) evaluate the feasibility of conducting a crossover pilot randomized controlled trial (RCT) for intervention testing in the ICU. A secondary objective is to examine the preliminary efficacy of the POMI to reduce pain in ICU patients.

METHODS

A single-blind 2×2 crossover pilot RCT will be conducted. Patients will undergo 1 sequence of 2 interventions: the POMI which delivers music based on patients' preferences via headphones or music pillow for 20-30 minutes and the control intervention (headphones or pillow without music). The sequence of the interventions will be inverted with a 4-hour washout period. Timing of the interventions will be before a planned bed turning procedure. Each patient will undergo 1 session of music. Twenty-four patients will be recruited. Patients able to self-report (n=12), family members of patients unable to self-report (n=12), and nursing staff (n=12) involved in the bed turning procedure will be invited to complete a short questionnaire on the POMI acceptability. Data will be collected on the feasibility of the intervention delivery (ie, time spent creating a playlist, any issue related to headphones/pillow or music delivery, environmental noises, and intervention interruptions) and research methods (ie, number of patients screened, recruited, randomized, and included in the analysis). Pain scores will be obtained before and after intervention delivery.

RESULTS

Recruitment and data collection began in March 2022. As of July 5, 2022, in total, 22 patients, 12 family members, and 11 nurses were recruited.

CONCLUSIONS

Methodological limitations and strengths are discussed. Study limitations include the lack of blinding for patients able to self-report. Strengths include collecting data from various sources, getting a comprehensive evaluation of the intervention, and using a crossover pilot RCT design, where participants act as their own control, thus reducing confounding factors.

TRIAL REGISTRATION

ClinicalTrials.gov NCT05320224; https://clinicaltrials.gov/ct2/show/NCT05320224.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/40760.

Health Care Professionals' Assessment of Patient Discomfort After Abdominal Surgery

PURPOSE

The purpose of this study was to classify elements of patients' discomfort in the resuscitation room after open or laparoscopic abdominal surgery as per health care professionals' perceptions.

DESIGN

A prospective cross-sectional study at a tertiary hospital in Spain.

METHODS

Resuscitation room nurses administered the Postoperative Discomfort Inventory to physicians and nurses with >1 year experience working closely with patients who had undergone abdominal surgery, asking them to score nine items related to patients' discomfort in the first 8 hours after surgery on an 11-point scale (0 = absent to 10 = very severe). Interobserver agreement among proxy reporters was measured with the Spearman's ρ; correlations >0.35 was considered adequate agreement.

FINDINGS

Of 125 eligible professionals, 116 (93%) participated (63 [54%] nurses and 53 [46%] physicians; mean age, 38 ± 12 years; 86 [74%] women). Professionals' perception of discomfort differed significantly between patients undergoing open surgery and those undergoing laparoscopic surgery; after open surgery, the most common types were pain (7.1 ± 1.8), movement restriction (7 ± 1.75), and dry mouth (6.6 ± 2.6), whereas after laparoscopic surgery, the most common types were dry mouth (5.85 ± 2.8), abdominal bloating (5.3 ± 2.5), and pain (5 ± 2.2). The Spearman's ρ correlations were inadequate for all items except for dry mouth in open surgery (r = 0.40).

CONCLUSIONS

Pain, movement restriction, abdominal bloating, and dry mouth were the main causes of discomfort. Our findings highlight the need to be vigilant for all manifestations of discomfort after abdominal surgery to enable timely treatment.

Suffering and Symptoms At the End of Life in ICU Patients Undergoing Renal Replacement Therapy

BACKGROUND

We know little about the end-of-life suffering and symptoms of intensive care unit (ICU) decedents in general and those who undergo renal replacement therapy (RRT) in particular.

OBJECTIVES

To examine differences in end-of-life suffering and various symptoms' contribution to suffering between ICU decedents who did not undergo RRT, those who underwent RRT for end-stage kidney disease (ESKD), and those who underwent RRT for acute kidney injury (AKI).

METHODS

This is a cross-sectional study conducted at a quaternary-level referral hospital September 2015-March 2017. Nurses completed interviews about ICU patients' suffering and symptoms in their final week. We dichotomized overall suffering into elevated and non-elevated and each symptom as contributing or not to a patient's suffering.

RESULTS

Sixty-four nurses completed interviews on 165 patients. Median patient age was 67 years (interquartile range 57, 78); 41% were female. In a multivariable model, undergoing RRT for AKI (odds ratio [OR] 2.95, 95% confidence interval [CI] 1.34-6.49) was significantly associated with elevated suffering compared to no RRT; undergoing RRT for ESKD was not. Adjusting for length of stay, AKI-RRT patients were more likely than non-RRT patients to have fecal incontinence (OR 2.21, 95% CI 1.00-4.93), painful broken skin (OR 2.41, 95% CI 1.14-5.12), and rashes (OR 3.61, 95% CI 1.35-9.67) contributing to their suffering.

CONCLUSIONS

Undergoing RRT for AKI was associated with elevated suffering in the last week of life in ICU decedents. Painful broken skin, rashes, and fecal incontinence were more likely to contribute to suffering in AKI-RRT patients than in non-RRT patients. How to reduce suffering associated with AKI-RRT in ICU patients merits further study.

The Effect of Caregiver-Facilitated Pain Management Interventions in Hospitalized Patients on Patient, Caregiver, Provider, and Health System Outcomes: A Systematic Review

CONTEXT

Alternative pain management interventions involving caregivers may be valuable adjuncts to conventional pain management interventions.

OBJECTIVES

Use systematic review methodology to examine caregiver-facilitated pain management interventions in a hospital setting and whether they improve patient, caregiver, provider, or health system outcomes.

METHODS

We searched MEDLINE, EMBASE, PsycINFO, CINAHL, and Scopus databases from inception to April 2020. Original research on caregiver-facilitated pain management interventions in hospitalized settings (i.e., any age) were included and categorized into three caregiver engagement strategies: inform (e.g., pain education), activate (e.g., prompt caregiver action), and collaborate (encourage caregiver's interaction with providers).

RESULTS

Of 61 included studies, most investigated premature (n = 27 of 61; 44.3%) and full-term neonates (n = 19 of 61; 31.1%). Interventions were classified as activate (n = 46 of 61; 75.4%), inform-activate-collaborate (n = 6 of 61; 9.8%), inform-activate (n = 5 of 61; 8.2%), activate-collaborate (n = 3 of 61; 4.9%), or inform (n = 1 of 61; 1.6%) caregiver engagement strategies. Interventions that included an activate engagement strategy improved pain outcomes in adults (18-64 years) (e.g., self-reported pain, n = 4 of 5; 80%) and neonates (e.g., crying, n = 32 of 41; 73.0%) but not children or older adults (65 years and older). Caregiver outcomes (e.g., pain knowledge) were improved by inform-activate engagement strategies (n = 3 of 3). Interventions did not improve provider (e.g., satisfaction) or health system (e.g., hospital length of stay) outcomes. Most studies were of low (n = 36 of 61; 59.0%) risk of bias.

CONCLUSION

Caregiver-facilitated pain management interventions using an activate engagement strategy may be effective in reducing pain of hospitalized neonates. Caregiver-facilitated pain management interventions improved pain outcomes in most adult studies; however, the number of studies of adults is small warranting caution pending further studies.

Role of Family Members in Pain Management in Adult Critical Care

This review describes family member involvement in intensive care unit pain assessment and management and generates implications for clinical practice, education, and future research. A literature review was performed in MEDLINE, PubMed, EMBASE, Cochrane, and CINAHL databases from their inception until April 30, 2019. Only 11 studies addressing the topic were identified, and the current quality of evidence is low. Family members can be involved in pain assessment by describing patients' pain behaviors and in pain management by selecting and delivering nonpharmacological interventions tailored to patients' needs, if the family members feel comfortable with this role. More-rigorous research is required to describe the role of family members in patients' pain assessment and management. Advancing knowledge in this field could improve patients' and family members' experiences with pain assessment and management in the intensive care unit.

Procedural Pain in the Adult Neurological Intensive Care Unit: A Retrospective Study Examining Arterial Line Insertion

BACKGROUND

This was a retrospective chart review of procedural pain assessments and interventions during arterial catheter insertion in an adult neurological intensive care unit where patients with impaired consciousness are common. Overall, pain assessment was well documented (100%) by Registered Nurses, but not specific to arterial line insertion. Nurse practitioners commonly placed arterial lines and used local analgesia in over 75% of the documented procedures.

AIMS

The purpose of this study was to examine healthcare providers' pain-related practices documented during arterial catheter insertion, one of the most painful procedures in a neurological intensive care unit. Secondary purposes were determining whether patient characteristics, procedure-related factors, or provider licensure were associated with pain assessment or procedural pain interventions.

DESIGN

A retrospective records review design was used.

METHODS

120 electronic patient medical records were reviewed during a one-year period.

RESULTS

100 charts met inclusion criteria. Nurses assessed all pain within 4 hours following the procedure in all charts but procedure-specific pain assessments were documented in 4% of charts. Pain-related interventions for arterial line insertion were local analgesic (76% of charts) and other procedure-specific interventions (10%). Significant associations occurred between procedure specific pain assessments and decreased number of insertion attempts (p = .006) and between pain interventions and number of insertion attempts (p = .003). No provider documented procedural pain assessment regarding arterial line insertion. Associations between patient characteristics and pain interventions were significant for patient ethnicity (F = 8.967, p = .007).

CONCLUSIONS

Overall pain assessment was documented (100%) but not specific to arterial line insertion. Although arterial line insertion can be extremely painful, patients were rarely assessed for such pain by any clinician; 14% did not receive any preprocedural analgesia.

CLINICAL IMPLICATIONS

The lack of procedural pain assessment in this vulnerable population indicates a need for increased pain management education for clinicians and further investigations to determine whether sufficient analgesia is provided to reduce procedural pain during arterial line insertion.

Dying Patient and Family Contributions to Nurse Distress in the ICU

RATIONALE

Caring for patients at the end of life is emotionally taxing and may contribute to burnout. Nevertheless, little is known about the factors associated with emotional distress in intensive care unit (ICU) nurses.

OBJECTIVES

To identify patient and family factors associated with nurses' emotional distress in caring for dying patients in the ICU.

METHODS

One hundred nurses who cared for 200 deceased ICU patients at two large academic medical centers in the Northeast United States were interviewed about patients' psychological and physical symptoms, their reactions to those patient experiences (e.g., emotional distress), and perceived factors contributing to their emotional distress. Logistic regression analyses modeled nurses' emotional distress as a function of patient symptoms and care.

RESULTS

Patients' overall quality of death (odds ratio [OR], 3.08; 95% confidence interval [CI], 1.31-7.25), suffering (OR, 2.34; CI, 1.03-5.29), and loss of dignity (OR, 2.95; CI, 1.19-7.29) were significantly associated with nurse emotional distress. Some 40.5% (79 of 195) of nurses identified families' fears of patient death, and 34.4% (67 of 195) identified families' unrealistic expectations as contributing to their own emotional distress.

CONCLUSIONS

Patients' emotional distress, physical distress, and perceived quality of death are associated with nurse emotional distress. Unrealistic family expectations for the patient may be a source of nurse emotional distress. Improving patients' quality of death, including enhancing their dignity, reducing their suffering, and promoting acceptance of an impending death among family members may improve the emotional health of nurses.

Pain Assessment in the Patient Unable to Self-Report: Clinical Practice Recommendations in Support of the ASPMN 2019 Position Statement

Pain is a subjective experience, unfortunately, some patients cannot provide a self-report of pain verbally, in writing, or by other means. In patients who are unable to self-report pain, other strategies must be used to infer pain and evaluate interventions. In support of the ASPMN position statement "Pain Assessment in the Patient Unable to Self-Report", this paper provides clinical practice recommendations for five populations in which difficulty communicating pain often exists: neonates, toddlers and young children, persons with intellectual disabilities, critically ill/unconscious patients, older adults with advanced dementia, and patients at the end of life. Nurses are integral to ensuring assessment and treatment of these vulnerable populations.

Clinical Practice Guidelines for the Prevention and Management of Pain, Agitation/Sedation, Delirium, Immobility, and Sleep Disruption in Adult Patients in the ICU

OBJECTIVE

To update and expand the 2013 Clinical Practice Guidelines for the Management of Pain, Agitation, and Delirium in Adult Patients in the ICU.

DESIGN

Thirty-two international experts, four methodologists, and four critical illness survivors met virtually at least monthly. All section groups gathered face-to-face at annual Society of Critical Care Medicine congresses; virtual connections included those unable to attend. A formal conflict of interest policy was developed a priori and enforced throughout the process. Teleconferences and electronic discussions among subgroups and whole panel were part of the guidelines' development. A general content review was completed face-to-face by all panel members in January 2017.

METHODS

Content experts, methodologists, and ICU survivors were represented in each of the five sections of the guidelines: Pain, Agitation/sedation, Delirium, Immobility (mobilization/rehabilitation), and Sleep (disruption). Each section created Population, Intervention, Comparison, and Outcome, and nonactionable, descriptive questions based on perceived clinical relevance. The guideline group then voted their ranking, and patients prioritized their importance. For each Population, Intervention, Comparison, and Outcome question, sections searched the best available evidence, determined its quality, and formulated recommendations as "strong," "conditional," or "good" practice statements based on Grading of Recommendations Assessment, Development and Evaluation principles. In addition, evidence gaps and clinical caveats were explicitly identified.

RESULTS

The Pain, Agitation/Sedation, Delirium, Immobility (mobilization/rehabilitation), and Sleep (disruption) panel issued 37 recommendations (three strong and 34 conditional), two good practice statements, and 32 ungraded, nonactionable statements. Three questions from the patient-centered prioritized question list remained without recommendation.

CONCLUSIONS

We found substantial agreement among a large, interdisciplinary cohort of international experts regarding evidence supporting recommendations, and the remaining literature gaps in the assessment, prevention, and treatment of Pain, Agitation/sedation, Delirium, Immobility (mobilization/rehabilitation), and Sleep (disruption) in critically ill adults. Highlighting this evidence and the research needs will improve Pain, Agitation/sedation, Delirium, Immobility (mobilization/rehabilitation), and Sleep (disruption) management and provide the foundation for improved outcomes and science in this vulnerable population.

Nurses' Assessment Practices of Pain Among Critically Ill Patients

BACKGROUND

Systematic pain assessment is necessary to ensure effective pain management. Despite the availability of recommendations, guidelines, and valid tools for pain assessment, the actual implementation in clinical practice is inconsistent.

AIMS

The purpose of this study was to investigate intensive care nurses' pain assessment practices among critically ill patients in Jordanian hospitals.

DESIGN

A descriptive cross sectional design was used in this study.

SETTINGS

This study was conducted in 22 intensive care unites located in eight hospitals in Jordan.

PARTICIPANTS/SUBJECTS

Convenience sampling was used to recruit a sample of 300 nurses working in intensive care units.

METHODS

The Pain Assessment and Management for the Critically Ill survey was used to collect data. Descriptive statistics, χ², and correlational analysis were used to analyze data.

RESULTS

A total of 89.7% of nurses (N = 300) used pain assessment tools with patients able to communicate, and the numeric rating scale was the most commonly used tool. A total of 81.7% of the nurses used a pain assessment tool with patients unable to communicate, and the Adult Nonverbal Pain Scale was the most commonly used tool. Nurses' perceived importance of pain assessment was positively associated with frequent use of pain assessment tools. Nurses perceived the use of pain assessment tools for patients able to communicate as being more important than the use of pain assessment tools for patients unable to communicate.

CONCLUSIONS

The majority of intensive care unit nurses used pain assessment tools for patients both able and unable to communicate; however, the most valid and reliable tools were not used often. Nurses were not aware of the pain behaviors most indicative of pain among critically ill patients.

Family Members' Experiences with Observing Pain Behaviors Using the Critical-Care Pain Observation Tool

BACKGROUND

Current guidelines support family members' participation in care, but little is known regarding their potential contribution to pain assessment using validated behavioral pain scales.

AIMS

This study aimed to describe family members' observations of pain behaviors with the Critical-Care Pain Observation Tool and their evaluation of the tool and its use, and to understand their experience and perceptions of their potential role in pain management in the intensive care unit.

DESIGN

A mixed methods cross-sectional explanatory design was used.

SETTING

A medical-surgical intensive care unit in Canada.

PARTICIPANTS/SUBJECTS

Family members were eligible if they had a loved one admitted in the intensive care unit who was unable to self-report.

METHODS

Family members identified pain behaviors using the Critical-Care Pain Observation Tool after a brief training, completed a self-administered questionnaire, and participated in a follow-up individual interview regarding their experience and perceived potential role in pain management when their loved one is unable to self-report.

RESULTS

Ten family members participated. A 15-minute training appeared sufficient for family members to be comfortable with observing pain behaviors included in the Critical-Care Pain Observation Tool. The tool allowed them to confirm their observations of pain behaviors, to focus more on the patient, and to advocate for better pain management.

CONCLUSIONS

Future research is needed to explore the views of more family members and to compare their Critical-Care Pain Observation Tool scores to the ones of nurses' for interrater reliability testing.

Validity, Reliability, and Diagnostic Accuracy of the Respiratory Distress Observation Scale for Assessment of Dyspnea in Adult Palliative Care Patients

BACKGROUND

The prevalence and severity of dyspnea increase at the end of life. Many of these patients have difficulty in reporting their symptoms. Accurate surrogate measures are needed for appropriate assessment and treatment. The Respiratory Distress Observation Scale (RDOS) is proposed as a possible scale although more external validation is needed. We set out to validate the RDOS in the context of palliative care patients near the end of life.

MEASURES

We prospectively studied 122 palliative care patients in a tertiary hospital in Singapore. Prior RDOS training was done using a standardized instructional video. Dyspnea was assessed by RDOS, Dyspnea Numerical Rating Scale, and Dyspnea Categorical Scale. Pain was assessed by Pain Numerical Rating Scale. We measured RDOS inter-rater reliability, convergent validity, and divergent validity. We used area under receiver operating characteristics curve (AUC) analysis to examine the discriminant properties of RDOS using dyspnea self-report as benchmark.

RESULTS

RDOS had good inter-rater reliability with an intraclass correlation of 0.947 (95% CI 0.919-0.976). It showed moderate-to-strong correlation with Dyspnea Numerical Rating Scale (r = 0.702) and Dyspnea Categorical Scale (r = 0.677) and negligible correlation to Pain Numerical Rating Scale (r = 0.080). It showed good discriminant properties of identifying patients with moderate and severe dyspnea with an AUC of 0.874 (95% CI 0.812-0.936). RDOS ≥ 4 predicted patients with moderate and severe dyspnea with a sensitivity of 76.6%, specificity of 86.2%, positive predictive value of 86.0%, and negative predictive value of 76.9%.

CONCLUSIONS

The RDOS shows promise and clinical utility as an observational dyspnea assessment tool. Further studies in uncommunicative patients are needed to determine clinical usefulness and generalizability of results.

Family members’ perceptions of pain behaviors and pain management of adult patients unable to self-report in the intensive care unit: A qualitative descriptive study

Background

Current guidelines suggest that family members be consulted in the pain assessment process of patients unable to self-report. However, little is known regarding family members’ perceptions of their loved one’s pain behaviors and pain management.

Aims

This qualitative descriptive study aimed to describe family members’ perceptions of pain behaviors and pain management in critically ill hospitalized patients admitted to an intensive care unit and unable to self-report.

Methods

A qualitative descriptive design was used. This study was conducted in a medical–surgical intensive care unit in Canada. Family members of nonverbal adult patients participated in a semistructured interview regarding their perceptions of pain behaviors and pain management in the intensive care unit.

Results

Ten family members with a nonverbal loved one admitted to the intensive care unit participated. Family members agreed on the presence of pain in the intensive care unit and reported being proactive and applying nonpharmacological interventions to help palliate pain of their loved one. Although family members identified behavioral indicators such as grimace, limb movement, and verbal complaints to assess pain in their loved one, the majority were unsure of their ability to detect pain.

Conclusions

Family members have intimate knowledge of their loved one and could be invited to share their perceptions of their loved one’s pain when they feel confident to do so.

Objective Nociceptive Assessment in Ventilated ICU Patients: A Feasibility Study Using Pupillometry and the Nociceptive Flexion Reflex

The concept of objective nociceptive assessment and optimal pain management have gained increasing attention. Despite the known negative short- and long-term consequences of unresolved pain or excessive analgosedation, adequate nociceptive monitoring remains challenging in non-communicative, critically ill adults. In the intensive care unit (ICU), routine nociceptive evaluation is carried out by the attending nurse using the Behavior Pain Scale (BPS) in mechanically ventilated patients. This assessment is limited by medication use (e.g., neuromuscular blocking agents) and the inherent subjective character of nociceptive evaluation by third parties. Here, we describe the use of two nociceptive reflex testing devices as tools for objective pain evaluation: the pupillary dilation reflex (PDR) and nociception flexion reflex (NFR). These measurement tools are non-invasive and well tolerated, providing clinicians and researchers with objective information regarding two different nociceptive processing pathways: (1) the pain-related autonomic reactivity and (2) the ascending component of the somatosensory system. The use of PDR and NFR measurements are currently limited to specialized pain clinics and research institutions because of impressions that these are technically demanding or time-consuming procedures, or even because of a lack of knowledge regarding their existence. By focusing on the two abovementioned nociceptive reflex assessments, this study evaluated their feasibility as a physiological pain measurement method in daily practice. Pursuing novel technologies for evaluating the analgesia level in unconscious patients may further improve individual pharmacological treatment and patient related outcome measures. Therefore, future research must include large well-designed clinical trials in a real-life environment.

Dyspnea

Dyspnea is a subjective experience of breathing discomfort that can only be known through a patient's report. Numeric rating or visual analog scales allow assessment of intensity when the patient can self-report. The Respiratory Distress Observation Scale is a valid, reliable tool for estimating distress when self-report cannot be elicited. Treating dyspnea begins with managing the underlying condition. Other dyspnea-specific evidence-based interventions include morphine and fentanyl, upright positioning, oxygen, invasive and noninvasive ventilation, and balancing rest with activity. Effectiveness has not been established for benzodiazepines, nebulized furosemide, oxygen in the face of normoxemia, other opioids, and nebulized fentanyl.

Pain, agitation, and delirium guidelines: nurses' involvement in development and implementation

The 2013 American College of Critical Care Medicine/Society of Critical Care Medicine clinical practice guidelines for the management of pain, agitation, and delirium in adult patients in the intensive care unit serves as a living example of nurses' involvement in the development and implementation of professional guidelines. Nurses who served on this guideline-writing panel describe their experiences. Specific examples from the pain, agitation, and delirium guidelines for care are used to explore the roles of the nurse leader, nurse informaticist, staff nurse, and nurse researcher in relationship to guideline implementation.

Satisfaction in the Intensive Care Unit (ICU). Patient opinion as a cornerstone

OBJECTIVE

To study the agreement between the level of satisfaction of patients and their families referred to the care and attention received during admission to the ICU.

DESIGN

A prospective, 5-month observational and descriptive study was carried out.

SETTING

ICU of Marqués de Valdecilla University Hospital, Santander (Spain).

SUBJECTS

Adult patients with an ICU stay longer than 24h, who were discharged to the ward during the period of the study, and their relatives.

INTERVENTION

Instrument: FS-ICU 34 for assessing family satisfaction, and an adaptation of the FS-ICU 34 for patients. The Cohen kappa index was calculated to assess agreement between answers.

RESULTS

An analysis was made of the questionnaires from one same family unit, obtaining 148 pairs of surveys (296 questionnaires). The kappa index ranged between 0.278-0.558, which is indicative of mild to moderate agreement.

CONCLUSIONS

The families of patients admitted to the ICU cannot be regarded as good proxies, at least for competent patients. In such cases, we must refer to these patients in order to obtain first hand information on their feelings, perceptions and experiences during admission to the ICU. Only when patients are unable to actively participate in the care process should their relatives be consulted.

The role of memories on health-related quality of life after intensive care unit care: an unforgettable controversy?

Background

Decreased health-related quality of life (HRQoL) is a significant problem after an intensive care stay and is affected by several known factors such as age, sex, and previous health-state. The objective of this study was to assess the association between memory and self-reported perceived HRQoL of patients discharged from the intensive care unit (ICU).

Methods

A prospective, multicenter study involving nine general ICUs in Portugal. All adult patients with a length of stay >48 hours were invited to participate in a 6-month follow-up after ICU discharge by answering a set of structured questionnaires, including EuroQol 5-Dimensions and ICU memory tool.

Results

A total of 313 (52% of the eligible) patients agreed to enter the study. The median age of patients was 60 years old, 58% were males, the median Simplified Acute Physiology Score II (SAPS II) was 38, and the median length of stay was 8 days for ICU and 21 days for total hospital stay. Eighty-nine percent (n=276) of the admissions were emergencies. Seventy-eight percent (n=234) of the patients had memories associated with the ICU stay. Patients with no memories had 2.1 higher chances (P=0.011) of being in the bottom half of the HRQoL score (<0.5 Euro-Qol 5-Dimensions index score). Even after adjusting for pre-admission characteristics, having memories was associated with higher perceived HRQoL (adjusted odds ratio =2.1, P=0.022).

Conclusion

This study suggests that most of the ICU survivors have memories of their ICU stay. For the ICU survivors, having memories of the ICU stay is associated with a higher perceived HRQoL 6 months after ICU discharge.

Quality of care and resource use among mechanically ventilated patients before and after an intervention to assist nurse-nonvocal patient communication

OBJECTIVES

Implement and test unit-wide patient-nurse assisted communication strategies (SPEACS).

BACKGROUND

SPEACS improved nurse-patient communication outcomes; effects on patient care quality and resource use are unknown.

METHODS

Prospective, randomized stepped-wedge pragmatic trial of 1440 adults ventilated ≥2 days and awake for at least one shift in 6 ICUs at 2 teaching hospitals 2009-2011 with blinded retrospective medical record abstraction.

MAIN RESULTS

323/383 (84%) nurses completed training; their communication knowledge (p < .001) and satisfaction and comfort (p < .001) increased. ICU days with physical restraint use (p = .44), heavy sedation (p = .73), pain score documentation (p = .97), presence of ICU-acquired pressure ulcers (p = .78), coma-free days (p = .76), ventilator-free days (p = .83), ICU length of stay (p = .77), hospital length of stay (p = .22), and median costs (p = .07) did not change.

CONCLUSIONS

SPEACS improved ICU nurses' knowledge, satisfaction and comfort in communicating with nonvocal MV patients but did not impact patient care quality or resource use.

Underestimation of Patient Breathlessness by Nurses and Physicians during a Spontaneous Breathing Trial

RATIONALE

Breathlessness is a prevalent and distressing symptom in intensive care unit patients. There is little evidence of the ability of healthcare workers to assess the patient's experiences of breathing. Patient perception of breathing is essential in symptom management, and patient perception during a spontaneous breathing trial (SBT) might be related to extubation success.

OBJECTIVES

To assess mechanically ventilated patients' experiences of breathlessness during SBT.

METHODS

This was a prospective observational multicenter study of 100 mechanically ventilated patients. We assessed the agreement between nurses, physicians, and patients' 11-point Numerical Rating Scales scores of breathlessness, perception of feeling secure, and improvement of respiratory function at the end of an SBT (most performed with some level of support). We also determined the association between breathlessness and demographic factors or respiratory observations.

MEASUREMENTS AND MAIN RESULTS

Sixty-two patients (62%) reported moderate or severe breathlessness (Numerical Rating Scales ≥ 4). The median intensity of breathlessness reported by patients was five compared with two by nurses and physicians (P < 0.001). Patients felt less secure and reported less improvement of respiratory function compared with nurses' and physicians' ratings. About half of the nurses and physicians underestimated breathlessness (difference score, ≤-2) compared with the patients' self-reports. Underestimation of breathlessness was not associated with professional competencies. There were no major differences in objective assessments of respiratory function in patients with moderate or severe breathlessness, and no apparent relationship between breathlessness during the SBT and extubation outcome.

CONCLUSIONS

Patients reported higher breathlessness after SBT compared with nurses and physicians. Clinical trial registered with www.clinicaltrials.gov (NCT 01928277).

Caring for Dying Patients in the Intensive Care Unit

Critically ill patients receiving palliative care at the end of life are at high risk for experiencing pain, dyspnea, and death rattle. Nearly all these patients are at risk for the development of delirium. Patients who are alert may experience anxiety. Advanced practice nurses and staff nurses are integral to detecting and treating these symptoms. Pain, dyspnea, and anxiety should be routinely assessed by patient self-report when possible. Routine behavioral screening for delirium is recommended. Behavioral observation tools to detect pain and dyspnea and proxy assessments guide symptom identification when the patient cannot provide a self-report. Evidence-based interventions are offered for both prevention and treatment of pain, dyspnea, anxiety, and delirium. Death rattle does not produce patient distress, and current pharmacological treatment lacks an evidence base. Pain management has a robust evidence base compared to management of dyspnea, anxiety, and delirium among this population; well-designed, adequately powered studies are needed.

Single-center large-cohort study into quality of life in Dutch intensive care unit subgroups, 1 year after admission, using EuroQoL EQ-6D-3L

PURPOSE

The goal of this study was to describe long-term survival and health-related quality of life (HRQoL), measured by EQ-6D, in a general intensive care unit (ICU) population.

MATERIALS AND METHODS

We included 5934 consecutive adult patients admitted to a mixed-population ICU. There were no exclusion criteria. One-year survival status was determined using the Dutch municipal population register. Subsequently, all survivors received the EuroQoL EQ-6D-3L questionnaire. The primary outcome was overall HRQoL and survival of the ICU survivors, compared to overall QoL of an age- and sex-matched reference population.

RESULTS

A total of 5138 patients (86.6%) survived until hospital discharge, with 4647 (78.3%) patients surviving the 1-year of follow-up. The EuroQoL questionnaire was sent to 4465 survivors and returned by 3034 (68.0%) of 4465. The median HRQoL in surviving patients was 0.83 (interquartile range [IQR], 0.64-1.00) vs 0.86 (IQR, 0.85-0.86) in the reference population (P < .001). There was marked variation across admission diagnosis groups: cardiac surgery patients had an HRQoL of 0.94 (IQR, 0.74-1.00), whereas patients admitted with chronic renal failure had an HRQoL of 0.65 (IQR, 0.47-0.83).

CONCLUSIONS

One year after ICU admission, HRQoL was significantly lower than in the reference population. Notably, marked variations were found across subgroups.

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

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.

ICU personnel have inaccurate perceptions of their patients' experiences

BACKGROUND

Intensive care unit (ICU) patient care bases - among others - upon the staff's assumptions about each patient's subjective preferences and experiences. However, these assumptions may be skewed and thus result in client-professional gaps (cp-gaps), which occur in two subtypes, hyperattention and blind spots to certain burdens. cp-gaps typically reduce quality of care. We investigated whether cp-gaps of either subtype exist in a 36-bed ICU of a university hospital.

METHODS

Observational study on 82 consecutive patients of a 36-bed university ICU, who voluntarily answered a psychometric questionnaire focusing on patients' experiences during an ICU stay. The questionnaire was reliable and valid (Cronbach's alpha, factor analysis). It consisted of 31 Likert-scaled items, which represented three scales of perception (communicative, intrapersonal, somatic) supplemented by 55 binary items for more specific information. Details of the questionnaire are given in the text. Demographic, educational, and medical data were registered too. Patients reported their subjective ICU experience 2-7 days after ICU discharge. Analogously, 60 staff members (physicians and nurses) reported their assumptions about patients' experiences. After correction for a general bias, group differences indicated cp-gaps.

RESULTS

Twelve cp-gaps were found. Hyperattention was found in four communicative and three intrapersonal items. Blind spots appeared in two communicative, two intrapersonal, and one somatic item. The pattern of cp-gap subtypes (hyperattention/blind spots) goes well with self-attributional bias - a model of social interaction.

CONCLUSIONS

cp-gaps in ICUs can be identified using analogue questionnaires for patients and staff. Both subtypes of cp-gap occur. cp-gaps are substantially influenced by self-attributional bias.