Pain Management in the Pediatric Palliative Care Population

By Thomas, Rene; Phillips, Marcia et al. | Journal of Nursing Scholarship, July 2018 | Go to article overview

Pain Management in the Pediatric Palliative Care Population


Thomas, Rene, Phillips, Marcia, Hamilton, Rebekah J., Journal of Nursing Scholarship


Advances in technology have brought an increase in options available for pediatric life-sustaining support. According to the Centers for Disease Control and Prevention's (CDC's) most recent Annual Summary of Vital Statistics, in 2013 there were nearly 2.6 million U.S. deaths (CDC, 2016). In that year, children 0 to 19 years of age accounted for 1.6% of all deaths, with 42,328 total deaths, a number that continues to decline (CDC, 2016; Friebert &Williams, 2015). More than half of all pediatric patients experience pain (Friedrichsdorf, Finney, Bergin, Stevens, & Collins, 2007; Friedrichsdorf et al., 2015).

The World Health Organization (WHO) defines pediatric palliative care as "the active total care of the child's body, mind, and spirit, [which] also involves giving support to the family" (WHO, 2016, 25). Pediatric palliative care encompasses the medical, psychosocial, spiritual, and economic needs of patients and provides patients with complex care from an interdisciplinary team of caregivers to reduce symptom severity and improve quality of life (Feudtner et al., 2013; Temel et al., 2010; WHO, 2016). Thus, it is paramount to address pain in the care of a pediatric palliative care patient across all age ranges to ensure "active total care" of the child (WHO, 2016). For children with terminal illnesses, palliative care and pain management are invaluable to patient care. The use of palliative care combats issues such as inadequate pain assessment and management, a lack of continuity of care, and treatment explanations (Feudtner et al., 2013; Moro, Kavanaugh, Okuno-Jones, & VanKleef, 2006). Pain management is an important component of patient care. The Joint Commission established standards for pain in 2001, and the Institute of Medicine, now called the National Academy of Medicine, released its report "Relieving Pain in America" in 2011 (National Research Council, 2011). The Joint Commission standards for pain focus on organizations having established policies regarding pain assessment and treatment and educating providers to ensure adherence to these policies (The Joint Commission, 2017). The Institute of Medicine recommends creating a detailed strategy both for pain management and prevention and for research (National Research Council, 2011).

Most diseases such as cancer, acute liver failure, or spinal muscular atrophy have pain as a symptom (Field & Behrman, 2005; Strassels et al., 2006). However, pain is often hard to manage especially with the pediatric population (Foster, Bell, Harris, & Gilmer, 2012; Strassels et al., 2006). Pain is difficult to manage because of many factors such as age, patients' ability to communicate, and patients' ability to comprehend their symptoms. Pain can be incapacitating and has a number of effects on children and their families, such as decreasing physicalmovement, interrupting sleep cycles, increasing stress, and increasing medical bills (Foster et al., 2012). The primary goals of pain management are consistent control of pain and, ideally, complete pain relief. Effective pain management uses modalities that include pharmacological measures, interventional procedures, and psychological measures.

Palliative care has differing complexities in the pediatric population because children comprehend illness and symptoms differently from adults. The pediatric population is still developing both cognitively and emotionally. Children between the ages of 2 and 6 years have an incomplete understanding of illness and death and often try out a variety of interpretations as they apply their limited experience to the puzzlement of death (Himelstein, 2006; WHO, 2008). In addition, the younger the child, the greater his or her dependence on others, difficulty in distinguishing between temporary and permanent absences, and fear of separation from family they have (Himelstein, 2006; WHO, 2008). Adolescents can explore the nonphysical (e.g., spiritual) explanations of death and critically think to connect observations, explanations, and their own understanding of their surroundings. …

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