Use of the assessment of discomfort in dementia protocol.

The Assessment of Discomfort in Dementia (ADD) Protocol was developed to improve recognition and treatment of physical pain and affective discomfort in people with dementia who are no longer able to clearly or consistently report on their internal states. The purpose of this study was to describe use of each step of the ADD protocol with 143 residents of long-term care facilities. Of the subjects who received nonpharmacological comfort interventions, 37% showed improved symptoms. Of the 91 protocols in which an analgesic was administered, 83.5% showed improved symptoms. People who complained verbally received considerably more analgesics and other comfort interventions. Limitations inherent in this descriptive exploratory study do not permit conclusions regarding the effectiveness of the ADD protocol. Research with a control group, random assignment, and objective measures of discomfort level is planned.

Building an institutional commitment to pain management in long-term care facilities.

This report reviews the development, implementation and findings of an inter-institutional study directed to the goal of making pain management an institutional priority in Wisconsin long-term care facilities. A total of 87 facilities were recruited in two training cohorts. Each facility identified a team of individuals, with responsibility and authority for care policies within their institution, to participate in four structured educational programs. Each team completed an Action Plan, structured around 14 national practice indicators of an institutional commitment to pain management. At baseline, 14% of facilities had > 51% of the indicators in place; at conclusion 74% of facilities had > 51% of indicators in place. This education project was successful across training cohorts at implementing critical pain management target indicators.

Nurses' perceptions of pain assessment and treatment in the cognitively impaired elderly. It's not a guessing game.

The purpose of the study was to describe nurses' perceptions regarding the assessment and treatment of pain in patients with late-stage dementia. Thirty nurses from six long-term care facilities were interviewed using a semistructured format for this qualitative study. Initial results were presented to a second group for validation and refinement of findings. The most commonly cited behaviors used to indicate discomfort were facial grimacing, restless body movement, change in behavior, moaning, and tense muscles. Psychotropic drugs were perceived to be commonly misused because behavior changes were seen as a psychiatric problem rather than a representation of the patient's unmet need. Nurses had positive feelings about using both narcotics and nonnarcotic analgesics with this population but believed both types of analgesics were underused. The most common concerns regarding the administration of narcotic analgesics to this population were falls, sedation, and constipation.

Assessment and treatment of discomfort for people with late-stage dementia.

People with dementia have often been excluded from pain studies. However, there is evidence supporting that people with dementia experience frequent pain, often poorly assessed and undertreated, and that the etiology for pain descriptions is poorly documented. The Assessment of Discomfort in Dementia (ADD) Protocol is designed to: a) more accurately assess discomfort in people with dementia who can no longer verbally describe physical pain or affective discomfort; b) more accurately and thoroughly treat physical pain and affective discomfort; and c) decrease inappropriate use of psychotropic medication. The use of the ADD Protocol was studies with a convenience sample of 104 residents of long-term care with end-stage dementia. Use of the ADD Protocol was associated with a significant decrease in discomfort (t = 6.56, p = 0.000). The most frequently seen behavioral symptoms associated with discomfort were tense body language, sad facial expression, fidgeting, perseverant verbalizations, and verbal outburts. The ADD Protocol was also associated with a significant increase in the use of scheduled analgesics and non-pharmacological comfort interventions. The protocol was not associated with an increase in the use of prn analgesics or with prn or scheduled psychotropics. This study has provided some support for the notion that the needs of people with significant dementia can be discerned and treated.

Integrating palliative care into daily practice: a nursing perspective.

Education of health care providers has historically been based on the traditional model of curative care. In this model, the curative care focus suddenly ends, substituted by a palliative approach to care, too often only in the last hours of life. Patient goals and wishes may never be clearly established, leaving family and care providers to guess at what the patient's wishes were. If we are to provide quality palliative care, we must equate it with health care providers establishing, acknowledging, and honoring patient and family goals. A major facilitator in accomplishing palliative care goals can arise from the nursing assessment. This article reviews the elements of a comprehensive nursing palliative care assessment (PCA). Although this article focuses on nurses, it has application for all health care professionals. Completion of the PCA provides an opportunity for reflection and evaluation of personal practices that support integrating palliative care into the care of all patients diagnosed with a life-threatening illness, beginning at the time of diagnosis and accelerating in intensity as the disease progresses.

Opioid equianalgesic calculations.

Among the knowledge required by healthcare professionals to manage pain is an understanding of the differences between opioid agents and formulations. As the list of new opioid formulations continues to grow, it is increasingly important that clinicians understand the basic pharmacology of these analgesics and how to calculate equianalgesic doses. Administering an equianalgesic dose increases the likelihood that the transition to another opioid or route will be tolerated without loss of pain control or excessive side effects. Although calculation of equianalgesic doses requires relatively simple mathematical skills, few clinicians are prepared to compute them. The purpose of this article is to provide a basic review of the pharmacology of opioids, explain how to calculate an equianalgesic dose, and briefly describe some of the current controversies of the relative potencies of opioids listed in equianalgesic tables.

Integration of palliative medicine at the Medical College of Wisconsin 1990-1996.

Palliative medicine is an emerging world-wide discipline. This article describes efforts at the Medical College of Wisconsin (MCW) to develop programs to enhance palliative medicine education and clinical care. New courses, seminars and clinical programs have been developed. Education and clinical care activities since 1990 have included a required course for second-year medical students, clinical electives for third- and fourth-year medical students, a clinical palliative care consultation service, a palliative care seminar series designed for housestaff, and a nurse preceptorship program. Palliative medicine activities have included both the academic medical center and community health agencies. MCW has integrated palliative medicine into its academic environment so that trainees at all education levels now have opportunities for didactic and clinical end-of-life care education.

A role model program to promote institutional changes for management of acute and cancer pain.

This report describes an 18-month project to make acute and cancer pain management an institutional priority in Southeastern Wisconsin health-care facilities. Facility-based teams, each of which included a nurse in a leadership position, were recruited to participate in a project based on the Cancer Pain Role Model Program. The project was conducted in three stages: (a) a 1-day conference focusing on basic pain management issues and clinical standards, (b) a preceptorship at the Medical College of Wisconsin, and (c) a follow-up conference focusing on institutional change. Participants completed an Action Plan, outlining activities aimed at changing practice in their facility. Participants from 17 of the 32 participating facilities partially or completely met their Action Plan goals. Lack of ongoing facility commitment, staff turnover and facility closures were cited as reasons for failure to meet goals. Nurses in key positions, provided with strong institutional commitment and given suitable educational training and nurturing, are ideally suited to help facilitate changes in institutional pain practices.

Palliative medicine nurse preceptorship at the Medical College of Wisconsin.

This article describes a 3-day nurse preceptorship education program in cancer pain and palliative medicine at the Medical College of Wisconsin (MCW). The program includes experiential and didactic information skills development, and assistance with planning for institutional change in the delivery of health care services. The education program is centered around five teaching modules: pain, nonpain symptoms, hospice, nursing professional issues, and palliative care. Evaluation data from a recent cohort of 23 nurses demonstrate that learning and personal objectives were met to a high degree of satisfaction.

The Palliative Care Consultation Service of the Medical College of Wisconsin.

Palliative care has not become a routine aspect of US academic medicine due to lack of reimbursement for clinical services, little research funding, and the perception that care for the terminally ill is not important in academic medical centers. This article describes the clinical activities of a new Palliative Care Consultation Service (PCS) for inpatients and outpatients, which was started at the Medical College of Wisconsin in April 1993. The goals of the PCS are to provide symptom control, assist with end-of-life decision making, and serve as a resource for appropriate discharge planning for all dying patients, not only those with cancer. Since its inception, an average of five consultations per week have been seen. Pain and end-of-life decisions were the most frequent reasons for consultation. Thirteen different clinical services consulted the PCS, most commonly internal medicine and oncology. Cancer and acquired immunodeficiency syndrome (AIDS) were the most frequent diagnoses. The PCS has also been used as a resource for assessment of inpatients with chronic nonmalignant pain who were believed to be drug addicts. The PCS has received widespread acceptance by the medical, nursing, and support staffs. The clinical and educational role of a dedicated palliative care service in academic medicine is discussed.