Clinical Practice Guidelines and Consensus Statements About Pain Management in Critically Ill End-of-life Patients

A Systematic Review

Alejandro Durán-Crane, MD; Andrés Laserna, MD; María A. López-Olivo, MD, PhD, MSC; John A. Cuenca, MD; Diana Paola Díaz, MD; Yenny Rocío Cardenas, MD, MSC; Catherine Urso, BS; Keara O'Connell, BMBS; Kian Azimpoor, BS; Clara Fowler, MSLS; Kristen J. Price, MD; Charles L. Sprung, MD, JD, MCCM; Joseph L. Nates, MD, MBA, CMQ, MCCM


Crit Care Med. 2019;47(11):1619-1626. 

In This Article

Abstract and Introduction


Objectives: To identify and synthesize available recommendations from scientific societies and experts on pain management at the end-of-life in the ICU.

Data Sources: We conducted a systematic review of PubMed, EMBASE, the Cochrane Database of Systematic Reviews, and Biblioteca Virtual en Salud from their inception until March 28, 2019.

Study Selection:We included all clinical practice guidelines, consensus statements, and benchmarks for quality.

Data Extraction: Study selection, methodological quality, and data extraction were performed independently by two investigators. A quality assessment was performed by four investigators using the Appraisal of Guidelines for Research and Evaluation II instrument. The recommendations were then synthesized and categorized.

Data Synthesis: Ten publications were included. The Appraisal of Guidelines for Research and Evaluation II statement showed low scores in various quality domains, especially in the applicability and rigor of development. Most documents were in agreement on five topics: 1) using a quantitative tool for pain assessment; 2) administering narcotics for pain relief and benzodiazepines for anxiety relief; 3) against prescribing neuromuscular blockers during withdrawal of life support to assess pain; 4) endorsing the use of high doses of opioids and sedatives for pain control, regardless of the risk that they will hasten death; and 5) using quality indicators to improve pain management during end-of-life in the ICU.

Conclusions: In spite of the lack of high-quality evidence, recommendations for pain management at the end-of-life in the ICU are homogeneous and are justified by ethical principles and agreement among experts. Considering the growing demand for the involvement of palliative care teams in the management of the dying patients in the ICU, there is a need to clearly define their early involvement and to further develop comprehensive evidence-based pain management strategies. Based on the study findings, we propose a management algorithm to improve the overall care of dying critically ill patients.


In the United States, approximately one in five people die in the ICU,[1] and palliative care in this setting has become an increasingly important practice. Approximately 40% of patients with a high probability of death and over half of the patients who are admitted to the ICU experience moderate to severe pain during their hospital stay.[2,3] Furthermore, the complexity of disease in the increasing proportion of elderly patients is leading to increased mortality from chronic illness in the critical care environment.[1]

Because of these trends, the need for high-quality palliative care for the critically ill is imperative and is currently at the foreground of quality improvement agendas for ICUs.[4] For example, the Robert Wood Johnson Foundation Critical Care End-of-Life Peer Workgroup has listed seven key quality benchmarks for palliative care in intensive care medicine, one of which is pain management.[5] Despite the priority of this issue, studies have shown that compliance with appropriate pain management during palliative care in the ICU is only present in 80% of cases.[6] Furthermore, observational studies have shown that care giver's satisfaction with the quality of pain control of their loved ones is variable; ranging from 47% to 86.9%,[7–10] indicating that this is an area that requires improvement.

With the growing number of terminally ill patients in the ICU and the integration of palliative care and critical care, adequate pain assessment and management at the end-of-life must be a top priority to provide patients with a dignified death.[4,11] Therefore, it is crucial to reach an agreement on the best evidence-based practices to control pain in this population. We conducted a systematic review and quality assessment of clinical practice guidelines and consensus statements from scientific societies and experts to identify and synthesize available recommendations for pain management at the end-of-life in the ICU.