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

Abstract

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.

Pain management during the withholding and withdrawal of life support in critically ill patients at the end-of-life: a systematic review and meta-analysis

“…Doses reported in many of the reviewed documents were higher than recommended dosages in guidelines for critically ill patients at the end-of-life [3]. This could be explained by the development of opioid tolerance in a considerable proportion of critically ill patients who are at the end-of-life, as evidenced by one study in which more than half of patients were already receiving opioids prior to withholding or withdrawing of life support [33].…”

“…Although there is homogeneity among end-of-life critical care guidelines, our systematic review showed a wide variation in practice and medication use, which could be attributed to the individualization of care recommended by guidelines, underuse of standardized protocols, or lack of guideline specificity in the recommendations [ 3 , 39 – 41 ]. Of note, among the more recent studies included in this review, we observed that the frequency of use was lower for morphine and higher for fentanyl compared to the earlier studies included.…”

“…Early cooperation with palliative care services could improve the final care these patients receive; additionally, the implementation of multimodal analgesia may also be beneficial at the end-of-life [ 2 , 3 , 45 – 47 ]. While the latter is favorable for patients in other circumstances, such as perioperative and trauma cases, we found a lack of evidence investigating this therapeutic approach during the withholding and withdrawal of life support [ 48 , 49 ].…”

“…Investigations of the characteristics of this population and the identification of shifts over time in clinical practice are allowing intensivists to better understand and manage patients at the end-of-life [2]. Several guidelines aiming to improve care for these patients have been developed; however, there is significant variation in the care critically ill patients receive at the end-of-life [2,3].…”

End-of-Life Issues in Intensive Care Units

“…80 A recent systematic review has highlighted the growing demand for the involvement of PC teams in the management of the dying patients in the ICU, the need to facilitate their early involvement, and to further develop comprehensive evidence-based pain management strategies. 81 A further complicating factor in the integration of PC in ICU practices is the fact that EoL care varies significantly between countries and health care systems. Practices and attitudes around death and dying are more hospital-centric in North America than in Europe but ICU admissions in the last days of life have the opposite distribution.…”