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1.  Quench the Thirst: Lessons from Clinical Thirst Trials 
Biological research for nursing  2013;16(4):456-466.
Thirst, as a symptom, has long been considered the most prevalent clinical complaint patients voice in healthcare settings. Yet, rarely have researchers examined thirst by its correlation with physiologic factors. This review was undertaken to examine the relationships between thirst ratings and factors mediating its primary physiologic correlates: plasma osmolality (pOsm) and arginine vasopressin peptide (AVP).
Methods
A literature search was undertaken to identify clinical studies in human subjects that investigated the relationship of thirst to specific physiologic thirst-related correlates and associated thirst mediators.
Findings
The 17 studies reviewed induced thirst by hyperosmolar infusion, through water deprivation or exercise weight-loss regimens. They confirmed intact osmotic thirst drives demonstrated by positive linear relationships between thirst ratings and rising serum pOsm levels. However, the normal compensatory rises in AVP levels that followed the rises in plasma osmolality varied. Alterations in AVP response were modified by exposure to cold, physical pre-conditioning and water immersion tests. Notably, older adults reported diminished thirst ratings. Weak correlations suggest that angiotensin II may play only a minor role in thirst mediation. Atrial natriuretic hormone’s inhibitory effect on thirst was inconsistent.
Conclusions
Older adults are at higher risk for profound dehydration due to sensory deficits along with failure to correct volume losses. Clinical thirst trials demonstrated that serum pOsm values were highly correlated with patients’ thirst ratings, with the exception of the older adult.
doi:10.1177/1099800413505900
PMCID: PMC3989478  PMID: 24136996
thirst; plasma osmolality; arginine vasopressin; dehydration; hypodipsia
2.  A Randomized Clinical Trial of an Intervention to Relieve Thirst and Dry Mouth in Intensive Care Unit Patients 
Intensive care medicine  2014;40(9):1295-1302.
Purpose
To test an intervention bundle for thirst intensity, thirst distress, and dry mouth, which are among the most pervasive, intense, distressful, unrecognized, and under-treated symptoms in ICU patients, but for which data-based interventions are lacking.
Methods
Single-blinded, randomized clinical trial in three ICUs in a tertiary medical center in urban California. 252 cognitively intact patients reporting thirst intensity (TI) and/or thirst distress (TD) scores ≥ 3 on 0–10 numeric rating scales (NRS) were randomized to Intervention or Usual Care groups. A Research Team Nurse (RTN#1) obtained patients’ pre-procedure TI and TD scores and reports of dry mouth. She then administered a thirst bundle to the Intervention group: oral swab wipes, sterile ice cold water sprays, and a lip moisturizer, or observed patients in the Usual Care group. RTN#2, blinded to group assignment, obtained post-procedure TI and TD scores. Up to 6 sessions per patient were conducted across two days.
Results
Multilevel linear regression determined that the average decreases in TI and TD scores from pre-procedure to post-procedure were significantly greater in the Intervention group (2.3 and 1.8 NRS points, respectively) versus the Usual Care group (0.6 and 0.4 points, respectively) (p < 0.05). The Usual Care group was 1.9 times more likely than the Intervention group to report dry mouth for each additional session on Day 1.
Conclusion
This simple, inexpensive thirst bundle significantly decreased ICU patients’ thirst and dry mouth and can be considered a practice intervention for patients experiencing thirst.
Clinical trial registered with www.clinicalTrials.gov (NCT01015755).
doi:10.1007/s00134-014-3339-z
PMCID: PMC4149585  PMID: 24894026
thirst relief; dry mouth; ICU; symptom; non-pharmacological; palliation
3.  Open visitation policies and practices in US ICUs: can we ever get there? 
Critical Care  2013;17(4):171.
Open visitation has been highly recommended by critical care groups but is not prevalent in practice. Here we discuss the present study on current visitation practices in US ICUs and discuss several factors affecting open visitation. We conclude with suggestions on achieving more liberal visitation practices.
doi:10.1186/cc12763
PMCID: PMC4056561  PMID: 23905784
4.  Predictors and use of non-pharmacologic interventions for procedural pain associated with turning among hospitalized adults 
Background
Many hospitalized adults cannot reposition themselves in their beds. Therefore, they are regularly turned by their nurses, primarily to prevent pressure ulcer formation. Previous research indicates that turning is painful and that patients are rarely pre-medicated with analgesics. Non-pharmacologic interventions may be used to help with this painful procedure. However, no published research was found on the use of non-pharmacologic interventions for turning of hospitalized patients.
Objectives
1) to describe patient pain characteristics during turning and their association with patient demographic and clinical characteristics; 2) to determine the frequency of use of various non-pharmacologic interventions for hospitalized adult patients undergoing the painful procedure of turning; and 3) to identify factors that predict the use of specific non-pharmacologic interventions for pain associated with turning.
Methods
Hospitalized adult patients who experienced turning, the nurses caring for them, and others who were present at the time of turning were asked if they used various non-pharmacologic interventions to manage pain during the turning.
Results
Of 1395 patients, 92.5% received at least one non-pharmacologic intervention. Most frequently used were calming voice (65.7%), information (60.6%), and deep breathing (37.9%). Critical care patients were more likely to receive a calming voice (OR= 1.66, p<.01); receive information (OR=1.62, p<.001); and use deep breathing (OR= 1.36, p<.05) than those who were not critical care patients. Those reporting higher pain were consistently more likely to receive each of the three interventions (OR=1.01, p<.05 for all 3).
Conclusions
Non-pharmacologic interventions are used frequently during a turning procedure. The specific interventions used most often are ones that can be initiated spontaneously. These data suggest that patients, nurses, and family members respond to patients’ turning-related pain by using non-pharmacologic interventions.
doi:10.1016/j.pmn.2010.02.004
PMCID: PMC3660704  PMID: 23688362
5.  Differences in Depression, Anxiety, and Quality of Life Between Women with and without Breast Pain Prior to Breast Cancer Surgery 
Purpose of the research
Little is known about the relationships between pain, anxiety, and depression in women prior to breast cancer surgery. The purpose of this study was to evaluate for differences in anxiety, depression, and quality of life (QOL) in women who did and did not report the occurrence of breast pain prior to breast cancer surgery. We hypothesized that women with pain would report higher levels of anxiety and depression as well as poorer QOL than women without pain.
Methods and sample
A total of 390 women completed self-report measures of pain, anxiety depression, and QOL prior to surgery.
Key Results
Women with preoperative breast pain (28%) were significantly younger, had a lower functional status score, were more likely to be Non-white and to have gone through menopause. Over 37% of the sample reported clinically meaningful levels of depressive symptoms. Almost 70% of the sample reported clinically meaningful levels of anxiety. Patients with preoperative breast pain reported significantly higher depression scores and significantly lower physical well-being scores. No between group differences were found for patients' ratings of state and trait anxiety or total QOL scores.
Conclusions
Findings from this study suggest that, regardless of pain status, anxiety and depression are common problems in women prior to breast cancer surgery.
doi:10.1016/j.ejon.2012.06.001
PMCID: PMC3524405  PMID: 22892272
breast pain; breast cancer surgery; anxiety; depression; quality of life; psychological distress
6.  Thirst in Critically Ill Patients: From Physiology to Sensation 
Critically ill patients often have distressful episodes of severe thirst, but the underlying complex biochemical, neurohormonal regulatory controls that regulate this primal sensation have rarely been addressed by clinicians. Subtle changes in plasma osmolality are the most potent stimulus for thirst. In response to increases in osmolality, osmoreceptors activate release of the neurohormone vasopressin (also known as antidiuretic hormone). The released vasopressin acts on the kidneys to conserve water to correct the hyperosmolar state. If this compensatory mechanism is unsuccessful, thirst arises to promote drinking. Thirst induced by marked volume loss, in contrast, is more closely related to the volemic and pressure changes regulated by the renin-angiotensin aldosterone system. Understanding the physiological mechanisms of thirst will help in understanding the pathophysiological consequences of underlying thirst-related disease and treatments in critically ill patients. Further clinical research is needed to elucidate the multiple inhibitory and excitatory neurohormonal stimuli that motivate patients’ intense desire for water.
doi:10.4037/ajcc2013533
PMCID: PMC3718499  PMID: 23817822
thirst; thirst sensation; thirst physiology; osmolality; vasopressin; anti-diuretic hormone; hypovolemia; dehydration; angiotensin II
7.  Challenge of assessing symptoms in seriously ill intensive care unit patients: Can proxy reporters help?* 
Critical care medicine  2012;40(10):2760-2767.
Objectives
Determine levels of agreement among intensive care unit patients and their family members, nurses, and physicians (proxies) regarding patients’ symptoms and compare levels of mean intensity (i.e., the magnitude of a symptom sensation) and distress (i.e., the degree of emotionality that a symptom engenders) of symptoms among patients and proxy reporters.
Design
Prospective study of proxy reporters of symptoms in seriously ill patients.
Settings
Two intensive care units in a tertiary medical center in the Western United States.
Patients
Two hundred and forty-five intensive care unit patients, 243 family members, 103 nurses, and 92 physicians.
Interventions
None.
Measurements and Main Results
On the basis of the magnitude of intraclass correlation coefficients, where coefficients from .35 to .78 are considered to be appropriately robust, correlation coefficients between patients’ and family members’ ratings met this criterion (≥.35) for intensity in six of ten symptoms. No intensity ratings between patients and nurses had intraclass correlation coefficients >.32. Three symptoms had intensity correlation coefficients of ≥.36 between patients’ and physicians’ ratings. Correlation coefficients between patients and family members were >.40 for five symptom-distress ratings. No symptoms had distress correlation coefficients of ≥.28 between patients’ and nurses’ ratings. Two symptoms had symptom-distress correlation coefficients between patients’ and physicians’ ratings at >.39. Family members, nurses, and physicians reported higher symptom-intensity scores than patients did for 80%, 60%, and 60% of the symptoms, respectively. Family members, nurses, and physicians reported higher symptom-distress scores than patients did for 90%, 70%, and 80% of the symptoms, respectively.
Conclusions
Patient–family intraclass correlation coefficients were sufficiently close for us to consider using family members to help assess intensive care unit patients’ symptoms. Relatively low intraclass correlation coefficients between intensive care unit clinicians’ and patients’ symptom ratings indicate that some proxy raters overestimate whereas others underestimate patients’ symptoms. Proxy overestimation of patients’ symptom scores warrants further study because this may influence decisions about treating patients’ symptoms.
doi:10.1097/CCM.0b013e31825b94d8
PMCID: PMC3712644  PMID: 22890258
concordance; critical care; intensive care unit; proxy reporters; symptoms; symptom assessment
9.  Training Nurses for Interdisciplinary Communication with Families in the Intensive Care Unit: An Intervention 
Journal of Palliative Medicine  2011;14(12):1325-1332.
Abstract
Background
Critical care nurse communication training has largely been limited to didactic materials, interactive training for nurse supervisors, or brief participatory learning programs within the context of comprehensive end-of-life care educational seminars. Preliminary evidence suggests that an interactive approach can also be effective in communication skills training for intensive care unit (ICU) nurses.
Methods
We implemented a 1-day educational intervention in five acute care hospitals within Veterans Integrated Service Network (VISN) 3 (New York-New Jersey region) of the Department of Veterans Affairs and focused solely on communication skills and targeted specifically to nurses providing bedside care for critically ill patients. A “learner centered” approach to skills training that has several integral components was employed. Among these are: a cognitive, evidence-based foundation upon which to build new skills; a method such as role-play that allows participants to practice newly learned skills; and an affective component, during which trainees can freely discuss their impressions of the exercise or explore difficulties that may have been encountered. Before and after the program we conducted a detailed assessment of participants' self-rated communication skills and of the techniques and materials we used.
Results and conclusions
Post-program responses documented significant improvement in self-evaluated skills for each of the core tasks we assessed. Evidence suggests that communication with patients and families in the ICU can be most effectively approached in an interdisciplinary way. For nurses to fully realize their potential for optimal communication as members of the multidisciplinary team, they must be equipped with the necessary skills. We believe this new program helps to expand the range of approaches for training nurses in essential communication skills.
doi:10.1089/jpm.2011.0225
PMCID: PMC3263486  PMID: 22132740
10.  The transition from acute to chronic pain: might intensive care unit patients be at risk? 
Pain remains a significant problem for patients hospitalized in intensive care units (ICUs). As research has shown, for some of these patients pain might even persist after discharge and become chronic. Exposure to intense pain and stress during medical and nursing procedures could be a risk factor that contributes to the transition from acute to chronic pain, which is a major disruption of the pain neurological system. New evidence suggests that physiological alterations contributing to chronic pain states take place both in the peripheral and central nervous systems. The purpose of this paper is to: 1) review cutting-edge theories regarding pain and mechanisms that underlie the transition from acute to chronic pain, such as increases in membrane excitability of peripheral and central nerve fibers, synaptic plasticity, and loss of the function of descending inhibitory pain fibers; 2) provide information on the association between the immune system and pain and its crucial contribution to development of chronic pain syndromes, and 3) discuss mechanisms at brain levels in the nervous system and their contribution to affective (i.e., emotional) states associated with chronic pain conditions. Finally, we will offer suggestions for ICU clinical interventions to attempt to prevent the transition from acute to chronic pain.
doi:10.1186/2110-5820-2-36
PMCID: PMC3488025  PMID: 22898192
Pain; Acute; Chronic; Acute-to-chronic; Intensive care unit; Critical care; Nerve sensitization
11.  Symptoms experienced by intensive care unit patients at high risk of dying 
Critical Care Medicine  2010;38(11):2155-2160.
Objective
To provide a focused, detailed assessment of the symptom experiences of intensive care unit patients at high risk of dying and to evaluate the relationship between delirium and patients' symptom reports.
Design
Prospective, observational study of patients' symptoms.
Setting
Two intensive care units in a tertiary medical center in the western United States.
Patients
One hundred seventy-one intensive care unit patients at high risk of dying.
Interventions
None.
Measurements and Main Results
Patients were interviewed every other day for up to 14 days. Patients rated the presence, intensity (1 = mild; 2 = moderate; 3 = severe), and distress (1 = not very distressing; 2 = moderately distressing; 3 = very distressing) of ten symptoms (that is, pain, tired, short of breath, restless, anxious, sad, hungry, scared, thirsty, confused). The Confusion Assessment Method–Intensive Care Unit was used to ascertain the presence of delirium. A total of 405 symptom assessments were completed by 171 patients. Patients' average age was 58 ± 15 yrs; 64% were males. Patients were mechanically ventilated during 34% of the 405 assessments, and 22% died in the hospital. Symptom prevalence ranged from 75% (tired) to 27% (confused). Thirst was moderately intense, and shortness of breath, scared, confusion, and pain were moderately distressful. Delirium was found in 34.2% of the 152 patients who could be evaluated. Delirious patients were more acutely ill and received significantly higher doses of opioids. Delirious patients were significantly more likely to report feeling confused (43% vs. 22%, p = .004) and sad (46% vs. 31%, p = .04) and less likely to report being tired (57% vs. 77%, p = .006) than nondelirious patients.
Conclusions
Study findings suggest that unrelieved and distressing symptoms are present for the majority of intensive care unit patients, including those with delirium. Symptom assessment in high-risk intensive care unit patients may lead to more focused interventions to avoid or minimize unnecessary suffering.
doi:10.1097/CCM.0b013e3181f267ee
PMCID: PMC3377582  PMID: 20711069
critical care; pain; symptoms; symptom assessment; palliative care; delirium
12.  Meeting standards of high-quality intensive care unit palliative care: Clinical performance and predictors 
Critical Care Medicine  2012;40(4):1105-1112.
Objectives
High-quality care for intensive care unit patients and families includes palliative care. To promote performance improvement, the Agency for Healthcare Research and Quality’s National Quality Measures Clearinghouse identified nine evidence-based processes of intensive care unit palliative care (Care and Communication Bundle) that are measured through review of medical record documentation. We conducted this study to examine how frequently the Care and Communication Bundle processes were performed in diverse intensive care units and to understand patient factors that are associated with such performance.
Design
Prospective, multisite, observational study of performance of key intensive care unit palliative care processes.
Settings
A surgical intensive care unit and a medical intensive care unit in two different large academic health centers and a medical-surgical intensive care unit in a medium-sized community hospital.
Patients
Consecutive adult patients with length of intensive care unit stay ≥5 days.
Interventions
None.
Measurements and Main Results
Between November 2007 and December 2009, we measured performance by specified day after intensive care unit admission on nine care process measures: identify medical decision-maker, advance directive and resuscitation preference, distribute family information leaflet, assess and manage pain, offer social work and spiritual support, and conduct interdisciplinary family meeting. Multivariable regression analysis was used to determine predictors of performance of five care processes. We enrolled 518 (94.9%) patients and 336 (83.6%) family members. Performances on pain assessment and management measures were high. In contrast, interdisciplinary family meetings were documented for <20% of patients by intensive care unit day 5. Performance on other measures ranged from 8% to 43%, with substantial variation across and within sites. Chronic comorbidity burden and site were the most consistent predictors of care process performance.
Conclusions
Across three intensive care units in this study, performance of key palliative care processes (other than pain assessment and management) was inconsistent and infrequent. Available resources and strategies should be utilized for performance improvement in this area of high importance to patients, families, and providers.
doi:10.1097/CCM.0b013e3182374a50
PMCID: PMC3307856  PMID: 22202706
13.  Integrating palliative care in the surgical and trauma intensive care unit: A report from the Improving Palliative Care in the Intensive Care Unit (IPAL-ICU) Project Advisory Board and the Center to Advance Palliative Care 
Critical Care Medicine  2012;40(4):1199-1206.
Objective
Although successful models for palliative care delivery and quality improvement in the intensive care unit have been described, their applicability in surgical intensive care unit settings has not been fully addressed. We undertook to define specific challenges, strategies, and solutions for integration of palliative care in the surgical intensive care unit.
Data Sources
We searched the MEDLINE database from inception to May 2011 for all English language articles using the term “surgical palliative care” or the terms “surgical critical care,” “surgical ICU,” “surgeon,” “trauma” or “transplant,” and “palliative care” or “end-of- life care” and hand-searched our personal files for additional articles. Based on review of these articles and the experiences of our interdisciplinary expert Advisory Board, we prepared this report.
Data Extraction and Synthesis
We critically reviewed the existing literature on delivery of palliative care in the surgical intensive care unit setting focusing on challenges, strategies, models, and interventions to promote effective integration of palliative care for patients receiving surgical critical care and their families.
Conclusions
Characteristics of patients with surgical disease and practices, attitudes, and interactions of different disciplines on the surgical critical care team present distinctive issues for intensive care unit palliative care integration and improvement. Physicians, nurses, and other team members in surgery, critical care and palliative care (if available) should be engaged collaboratively to identify challenges and develop strategies. “Consultative,” “integrative,” and combined models can be used to improve intensive care unit palliative care, although optimal use of trigger criteria for palliative care consultation has not yet been demonstrated. Important components of an improvement effort include attention to efficient work systems and practical tools and to attitudinal factors and “culture” in the unit and institution. Approaches that emphasize delivery of palliative care together with surgical critical care hold promise to better integrate palliative care into the surgical intensive care unit.
doi:10.1097/CCM.0b013e31823bc8e7
PMCID: PMC3307874  PMID: 22080644
end-of-life care; ICU palliative care; surgeon attitude; surgical intensive care; surgical outcome; surgical palliative care
14.  Studying Physician-Patient Communication in the Acute Care Setting: The Hospitalist Rapport Study 
Patient education and counseling  2010;82(2):275-279.
Objective
To assess the feasibility of studying physician-patient communication in the acute care setting.
Methods
We recruited hospitalist physicians and patients from two hospitals within a university system and audio-recorded their first encounter. Recruitment, data collection, and challenges encountered were tracked.
Results
Thirty-two physicians consented (rate 91%). Between August 2008 and March 2009, 441 patients were referred, 210 (48%) were screened, and 119 (66% of 179 eligible) consented. We audio-recorded encounters of 80 patients with 27 physicians. Physicians’ primary concern about participation was interference with their workflow. Addressing their concerns and building the protocol around their schedules facilitated participation. Challenges unique to the acute care setting were: 1) extremely limited time for patient identification, screening, and enrollment during which patients were ill and busy with clinical care activities, and 2) little advance knowledge of when physician-patient encounters would occur. Employing a full-time study coordinator mitigated these challenges.
Conclusion
Physician concerns for participating in communication studies are similar in ambulatory and acute care settings. The acute care setting presents novel challenges for patient recruitment and data collection.
Practice Implications
These methods should be used to study provider-patient communication in acute care settings. Future work should test strategies to increase patient enrollment.
doi:10.1016/j.pec.2010.04.015
PMCID: PMC3025053  PMID: 20444569
Physician-patient communication; Hospital; Methodology
15.  Models for structuring a clinical initiative to enhance palliative care in the intensive care unit: A report from the IPAL-ICU Project (Improving Palliative Care in the ICU)* 
Critical Care Medicine  2010;38(9):1765-1772.
Objective
To describe models used in successful clinical initiatives to improve the quality of palliative care in critical care settings.
Data Sources
We searched the MEDLINE database from inception to April 2010 for all English language articles using the terms “intensive care,” “critical care,” or “ICU” and “palliative care”; we also hand-searched reference lists and author files. Based on review and synthesis of these data and the experiences of our interdisciplinary expert Advisory Board, we prepared this consensus report.
Data Extraction and Synthesis
We critically reviewed the existing data with a focus on models that have been used to structure clinical initiatives to enhance palliative care for critically ill patients in intensive care units and their families.
Conclusions
There are two main models for intensive care unit–palliative care integration: 1) the “consultative model,” which focuses on increasing the involvement and effectiveness of palliative care consultants in the care of intensive care unit patients and their families, particularly those patients identified as at highest risk for poor outcomes; and 2) the “integrative model,” which seeks to embed palliative care principles and interventions into daily practice by the intensive care unit team for all patients and families facing critical illness. These models are not mutually exclusive but rather represent the ends of a spectrum of approaches. Choosing an overall approach from among these models should be one of the earliest steps in planning an intensive care unit–palliative care initiative. This process entails a careful and realistic assessment of available resources, attitudes of key stakeholders, structural aspects of intensive care unit care, and patterns of local practice in the intensive care unit and hospital. A well-structured intensive care unit–palliative care initiative can provide important benefits for patients, families, and providers.
doi:10.1097/CCM.0b013e3181e8ad23
PMCID: PMC3267548  PMID: 20562699
intensive care; critical care; palliative care
16.  In their own words: Patients and families define high-quality palliative care in the intensive care unit* 
Critical Care Medicine  2010;38(3):808-818.
Objective
Although the majority of hospital deaths occur in the intensive care unit and virtually all critically ill patients and their families have palliative needs, we know little about how patients and families, the most important “stakeholders,” define high-quality intensive care unit palliative care. We conducted this study to obtain their views on important domains of this care.
Design
Qualitative study using focus groups facilitated by a single physician.
Setting
A 20-bed general intensive care unit in a 382-bed community hospital in Oklahoma; 24-bed medical–surgical intensive care unit in a 377-bed tertiary, university hospital in urban California; and eight-bed medical intensive care unit in a 311-bed Veterans’ Affairs hospital in a northeastern city.
Patients
Randomly-selected patients with intensive care unit length of stay ≥5 days in 2007 to 2008 who survived the intensive care unit, families of survivors, and families of patients who died in the intensive care unit.
Interventions
None.
Measurements and Main Results
Focus group facilitator used open-ended questions and scripted probes from a written guide. Three investigators independently coded meeting transcripts, achieving consensus on themes. From 48 subjects (15 patients, 33 family members) in nine focus groups across three sites, a shared definition of high-quality intensive care unit palliative care emerged: timely, clear, and compassionate communication by clinicians; clinical decision-making focused on patients’ preferences, goals, and values; patient care maintaining comfort, dignity, and personhood; and family care with open access and proximity to patients, interdisciplinary support in the intensive care unit, and bereavement care for families of patients who died. Participants also endorsed specific processes to operationalize the care they considered important.
Conclusions
Efforts to improve intensive care unit palliative care quality should focus on domains and processes that are most valued by critically ill patients and their families, among whom we found broad agreement in a diverse sample. Measures of quality and effective interventions exist to improve care in domains that are important to intensive care unit patients and families.
PMCID: PMC3267550  PMID: 20198726
intensive care; critical care; palliative care; quality assessment; health care; quality indicators; qualitative research
17.  Integrating Palliative Care in the ICU 
Palliative care is increasingly recognized as an integral component of comprehensive intensive care for all critically ill patients, regardless of prognosis, and for their families. Here we discuss the key role that nurses can and must continue to play in making this evidence-based paradigm a clinical reality across a broad range of ICUs. We review the contributions of nurses to implementation of ICU safety initiatives as a model that can be applied to ICU palliative care integration. We focus on the importance of nursing involvement in design and application of work processes that facilitate this integration in a systematic way, including processes that ensure the participation of nurses in discussions and decision making with families about care goals. We suggest ways that nurses can help to operationalize an integrated approach to palliative care in the ICU and to define their own essential role in a successful, sustainable ICU palliative care improvement effort. Finally, we identify resources including The IPAL-ICU Project™, a new initiative by the Center to Advance Palliative Care that can assist nurses and other healthcare professionals to move such efforts forward in diverse critical care settings.
doi:10.1097/NJH.0b013e318203d9ff
PMCID: PMC3162372  PMID: 21874122
intensive care; nurse's role; palliative care
18.  The Epidemiology of Pain During the Last Two Years of Life 
Annals of internal medicine  2010;153(9):563-569.
Background
The epidemiology of pain during the last years of life has not been well described.
Objective
To describe the prevalence and correlates of pain over the last two years of life.
Design
Observational study. We analyzed data from subjects who died while enrolled in the Health and Retirement Study. The survey interview closest to death was used. Each subject or proxy was interviewed once in the last 24 months of life and were classified into one of 24 cohorts based on the number of months between the interview and death. We modeled the relationship between time before death and pain adjusted for age, gender, race/ethnicity, education, net worth, income, terminal diagnosis category, arthritis, and proxy status.
Setting
The Health and Retirement Study, a nationally representative survey of community-living older adults (1994–2006).
Participants
Older adult decedents.
Measurements
Significant pain as indicated by a report that the subject was “often troubled” by pain of at least moderate severity.
Results
The sample included 4,703 decedents (mean age [SD] 75.7 [10.8], 83.1% white, 10.7% black, 4.7% Hispanic, 52.3% men). The adjusted prevalence of pain 24 months prior to death was 26% (95% CI, 23–30%). The prevalence remained flat until 4 months prior to death (28%, 25–32%), then increased, reaching 46% (38–55%) in the last month of life. The prevalence of pain in the last month of life was 60% among patients with arthritis vs. 26% among patients without arthritis (p<.001), and did not differ by terminal diagnosis category (cancer 45%, heart disease 48%, frailty 50%, sudden death 42%, other 47%, p=0.195).
Limitations
cross sectional data; 19% proxy responses; information about cause, location, and treatment of pain not available.
Conclusions
While the prevalence of pain increases in the last 4 months of life, pain is present in over a quarter of elders over the last 2 years of life. Arthritis is strongly associated with pain at the end of life.
Primary Funding Source
National Institute on Aging; National Center for Research Resources; National Institute on Musculoskeletal and Skin Diseases; National Palliative Care Research Center.
doi:10.1059/0003-4819-153-9-201011020-00005
PMCID: PMC3150170  PMID: 21041575
19.  Ensuring Cross-Cultural Equivalence in Translation of Research Consents and Clinical Documents 
The aim of this article is to describe a formal process used to translate research study materials from English into traditional Chinese characters. This process may be useful for translating documents for use by both research participants and clinical patients. A modified Brislin model was used as the systematic translation process. Four bilingual translators were involved, and a Flaherty 3-point scale was used to evaluate the translated documents. The linguistic discrepancies that arise in the process of ensuring cross-cultural congruency or equivalency between the two languages are presented to promote the development of patient-accessible cross-cultural documents.
doi:10.1177/1043659608325852
PMCID: PMC2834476  PMID: 18948451
cultural research; methodological research; translation; recruit and retain participants

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