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Clinical Practice Guidelines and Consensus Statements About Pain Management in Critically Ill End-of-Life Patients: A Systematic Review

Durán-Crane, Alejandro MD1; Laserna, Andrés MD2; López-Olivo, María A. MD, PhD, MSC3; Cuenca, John A. MD2; Díaz, Diana Paola MD1; Cardenas, Yenny Rocío MD, MSC1; Urso, Catherine BS2; O’Connell, Keara BMBS2; Azimpoor, Kian BS2; Fowler, Clara MSLS4; Price, Kristen J. MD2; Sprung, Charles L. MD, JD, MCCM5; Nates, Joseph L. MD, MBA, CMQ, MCCM2

doi: 10.1097/CCM.0000000000003975
Review Articles

Objectives: To identify and synthesize available recommendations from scientific societies and experts on pain management at the end-of-life in the ICU.

Data Sources: We conducted a systematic review of PubMed, EMBASE, the Cochrane Database of Systematic Reviews, and Biblioteca Virtual en Salud from their inception until March 28, 2019.

Study Selection: We included all clinical practice guidelines, consensus statements, and benchmarks for quality.

Data Extraction: Study selection, methodological quality, and data extraction were performed independently by two investigators. A quality assessment was performed by four investigators using the Appraisal of Guidelines for Research and Evaluation II instrument. The recommendations were then synthesized and categorized.

Data Synthesis: Ten publications were included. The Appraisal of Guidelines for Research and Evaluation II statement showed low scores in various quality domains, especially in the applicability and rigor of development. Most documents were in agreement on five topics: 1) using a quantitative tool for pain assessment; 2) administering narcotics for pain relief and benzodiazepines for anxiety relief; 3) against prescribing neuromuscular blockers during withdrawal of life support to assess pain; 4) endorsing the use of high doses of opioids and sedatives for pain control, regardless of the risk that they will hasten death; and 5) using quality indicators to improve pain management during end-of-life in the ICU.

Conclusions: In spite of the lack of high-quality evidence, recommendations for pain management at the end-of-life in the ICU are homogeneous and are justified by ethical principles and agreement among experts. Considering the growing demand for the involvement of palliative care teams in the management of the dying patients in the ICU, there is a need to clearly define their early involvement and to further develop comprehensive evidence-based pain management strategies. Based on the study findings, we propose a management algorithm to improve the overall care of dying critically ill patients.

1Department of Critical Care, Fundación Santa Fe de Bogotá, Bogotá, Colombia.

2Department of Critical Care, Division of Anesthesiology, Critical Care and Pain Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX.

3Department of Internal Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX.

4Research Medical Library, The University of Texas MD Anderson Cancer Center, Houston, TX.

5Department of Anesthesiology and Critical Care Medicine, Hadassah Medical Center, Hebrew University of Jerusalem, Faculty of Medicine, Jerusalem, Israel.

Drs. Durán-Crane and Laserna contributed equally.

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Dr. Durán-Crane disclosed he was previously employed by Fundacion Santa Fe de Bogotá, Colombia. Dr. Lopez-Olivo’s work is supported by a career award from the Rheumatology Research Foundation. Dr. Nates’ institution received funding from the George Sweeney Fellowship grant of the MD Anderson resources grant. The remaining authors have disclosed that they do not have any potential conflicts of interest.

Systematic Review Registration: PROSPERO Number CRD42018089489.

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