Assessing and Treating Pain in the Nonverbal Patient
In this particular case, the nurses felt there was a level of suffering that L.J. likely experienced that could not have been documented using validated pain and agitation scores. The pain being described was witnessed directly by the eyes of the nurses performing daily care and dressing changes at the bedside. In their attempts to advocate for patient comfort and dignity at EOL, the ICU nurses felt their concerns were being dismissed by team members. Meanwhile, the ICU fellow on call worried that giving opioids in the setting of hypotension and no documented evidence of pain could potentially hasten L.J.'s death. This calls attention to one of many challenges in the ICU, which is the assessment and management of symptoms in nonverbal, critically ill patients.
Pain, as well as other symptoms, has been well documented in the ICU, so much so that guidelines have been published for assessment and ongoing management. The pain, agitation, and delirium practice guidelines for adult critically ill patients are supported by research that has identified the presence of pain in ICU patients as high as 50% at rest. Incidence increased up to 80% during the common care procedures performed in the ICU, including turning, tracheal suctioning, wound care, and placement and removal of drains and central lines. For the patients who survived ICU admission, pain was linked to greater risks for posttraumatic stress disorder when uncontrolled and reduced duration of mechanical ventilation, ICU-acquired infections, and length of stay when well controlled. For patients who are cognitively impaired, symptom experience remains less understood.
The Improving Palliative Care in the ICU Project has addressed relieving common distressing symptoms of pain, dyspnea, and thirst in the ICU. Evaluation of current standards and evidence supports that self-report of pain and other symptoms remains the criterion standard of assessment. When patients are noncommunicative, validated behavioral symptom assessment scores using the Behavior Pain Scale or the Critical Care Pain Observation Tool have been helpful in understanding pain levels in adult patients without brain injury. Findings of these tools, however, are still an indirect representation of a patient's true perception of pain.
Proxy assessment by either family or clinicians when self-report and behavioral assessment scores cannot be used remains somewhat controversial. Although family members have been found to overestimate pain, data suggest that report by proxy can help identify normal sources of distress for the patient and their past response to management. Clinicians should also use their experience and judgment to identify potential sources of discomfort for the patient and treat symptoms appropriately using evidence-based approaches to care.
Pain and symptoms should be routinely monitored and documented. If pain is thought to be present, initiating analgesic trials is recommended using low doses of fast-acting opioids to monitor for improvement of symptoms or pain-related behaviors. Putting a plan of action in place and discussing this with family and bedside clinicians are essential to ensure that all parties have a clear understanding of how symptoms will be managed. This also provides the opportunity for all members of the care team to voice any questions or concerns that may be present. In L.J.'s case, the nurses reported that she previously had severe pain with dressing changes requiring premedication and postmedication with opioids, which should have prompted an evaluation by the care provider. The nurses' concerns should have also been sufficient reason to provide an analgesic regimen that took into consideration what was needed in the past to tolerate a similar level of care.
Despite recommended guidelines, these methods of evaluation when the patient cannot self-report pain or distress may not necessarily alleviate provider concerns about secondary effects of opioids. Secondary effects can include hypotension, sedation, respiratory depression, delirium, and agitation. Treating pain in the presence of physiologic instability remains a concern for many ICU clinicians, especially those in training that may not have been exposed to the full spectrum of ICU patients and outcomes. Regardless, fear of physiologic instability should never prevent clinicians from assessing and treating pain in this patient population vulnerable to suffering at EOL. Treatment of pain is not limited to opioids, and all available ICU resources must be utilized to optimize comfort. Feelings of uncertainty should prompt any clinician to seek advice from colleagues with more experience, supervisors, and/or from palliative care specialists.