Position Paper on Pain Management During End-of-Life Care

adolescent, the family, and other members of the inter- disciplinary healthcare team to develop goals of care and the pain management plan. Assessment Early identification of pain, worsening pain, and uncontrolled pain allows the nurse to advocate for the appropriate pain management plan that will reduce pain and suffering at the end of life. Nurses, whether in the inpatient hos- pital setting, the outpatient clinic, or the patient’s home, should assess pain and the effectiveness of the current plan at regular intervals. Comfort or level of pain may be assessed primarily through the use of self-report scales that are age appropriate, reliable, and valid. The nurse should take into consideration the unique developmen- tal needs of the child or adolescent. The parents or other family members may also contribute a subjective assess- ment of the child or adolescent’s pain and provide details about pain strategies that have previously been suc- cessful. The nurse should also assess objective data, including vital signs, general appearance, and response to touch or movement. The nurse may also assess the patient’s and family’s understanding of pain management and the dying process and the support systems that are available in the family, the interdisciplinary healthcare team, and the community. Planning The nurse, in collaboration with the interdisciplinary team, the patient, and the family, works to develop a holistic pain management plan aimed at meeting the goals of care and determining the appropriate methods of symptom and pain management. The nurse should

incorporate education into the plan of care, covering symptoms of uncontrolled pain, delivery of pain interven- tions, potential side effects of therapies, and the appro- priate time to contact the healthcare team if the child’s or adolescent’s care is being managed at home. Implementation The nurse identifies and performs interventions that are based on current knowledge of pain assessment and management in children and adolescents. The inter- ventions are congruent with the age, cognitive ability, and goals of care for the child or adolescent. Interven- tions may include the delivery of pain medications and the use of adjuvant therapies and nonpharmacologic approaches. The nurse will also need to educate fami- lies on the delivery of these interventions. The nurse is responsible for documenting in the medical record the intervention and the patient’s response and ensuring that these are communicated to all members of the health- care team. Evaluation The evaluation of all pain management interventions is crucial. The nurse should also educate the family about the importance of reevaluation following pain manage- ment interventions. The nurse should continually assess the patient’s response to treatment and evaluate the need for changes in the plan of care. The pain manage- ment plan is subsequently based on the assessment and evaluation of the nurse in collaboration with the interdis- ciplinary healthcare team, the child or adolescent, and the family.

References American Academy of Pediatrics. Section on Hospice and Palliative Medicine and Committee on Hospital Care. (2013). Pediatric palliative care and hospice care commitments, guidelines, and recommendations. Pediatrics, 132 , e20132731. American Nurses Association. (2015). Code of ethics for nurses with interpretive statements. https://www.nursingworld.org/coe- view-only Anekar, A. A., & Cascella, M. (2020). WHO Analgesic Ladder . In StatPearls [Internet]. StatPearls Publishing. Updated May 17, 2020. https://www.ncbi.nlm.nih.gov/books/NBK554435/ Association of Pediatric Hematology/Oncology Nurses. (2014). Scope and standards of pediatric hematology/oncology nursing practice . Chicago, IL. Berlinger, N., Jennings, B., & Wolf, S. M. (2013). The Hastings Center guidelines for decisions on life sustaining treatment and care near the end of life (2nd ed.). Oxford University Press. Brown, M. L., Rojas, E., & Gouda, S. (2017). A mind-body approach to pediatric pain management. Children (Basel, Switzerland), 4 (6), 50. https://doi.org/10.3390/children4060050 Duffy, E. A., Dias, N., Hendricks-Ferguson, V., Hellsten, M., Skeens-Borland, M., Thornton, C., & Linder, L. A. (2019). Perspectives on cancer pain assessment and management in children. Seminars in Oncology Nursing, 35 (3), 261–273. https://doi.org/10.1016/j. soncn.2019.04.007 Eche, I. J., Eche, I. M., & Aronowitz, T. (2020). An integrative review of factors associated with symptom burden at the end of life in children with cancer. Journal of Pediatric Oncology Nursing, 37 (4), 284–295. https://doi.org/10.1177/1043454220909805