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


This article is the first systematic review that summarizes the guidelines and recommendations of pain management at the end-of-life in the ICU. Most of these were based on either ethical principles or expert opinions. Despite the lack of evidence-based literature supporting the use of any intervention over another, we found consensus on several palliative care recommendations for critically ill patients at the end-of-life. The summary of the recommendation suggests that a proper understanding of the entire process, from pain assessment to pain management available interventions, and multidisciplinary collaboration, is fundamental for achieving adequate pain control. Based on the findings of this review, we have created a management algorithm that may improve the care of dying patients in the ICU, and its validation is paramount (Figure 2; and Supplementary Table 4, Supplemental Digital Content 1,

Figure 2.

Pain management algorithm for the critically ill patients at the end-of-life.

Regarding pain assessment, the recommendations agree on using a systematic method for patient evaluation. Although there is no consensus on what specific pain assessment scale should be used, the presence of any systematic form of ongoing pain assessment implementable by ICU staff may be sufficient. Adequate and continuous pain assessment should be encouraged, as is recommended by the majority of published guidelines and their supporting literature.[24] Managing dying patients imposes barriers that make pain assessment a challenge, which may become even more significant under the influence of neuromuscular blockers; thus, most guidelines recommend against their administration and shed light to the importance of weaning them during the end-of-life process. If neuromuscular blockers are required, an appropriate justification for their administration should be documented.[20]

Regarding pain management interventions, most guidelines recommend the use of opioids and benzodiazepines for symptom relief. Bolus and infusions are recommended depending on the status of the patient and the availability of IV access, with the alternative of using subcutaneous medications if IV access is not available or oral medications if the patient can swallow. Concerning titration, all documents were emphatic regarding the importance of titrating-up dosages until pain and suffering are relieved, without having a maximum dosage. Starting dosages should be adjusted individually depending on patient characteristics and clinical conditions. In light of the lack of comparative evidence for specific medications, we believe that using the drug the intensivist is most familiar with is good practice. The appropriate documentation of dose adjustment is essential during titration and marks the difference between shortening the dying process and relieving suffering.[22]

Nonpharmacologic interventions are also crucial for the adequate management of dying patients and guaranteeing a peaceful environment should be paramount. To that end, the presence of family, friends, and spiritual care, if desired, should be offered and secured, as well as the avoidance of any intervention that may cause pain or suffering.[17,19,20] Regarding adjuvant medications, some guidelines highlight the importance of preventing or identifying side effects associated with opioids as a way to improve the quality of death. Adjuvant medications should be ready to be administered in the event of these side effects being suspected.[15,16]

Critical care practitioners should develop a routine collaboration with palliative care specialists so that timely intervention can be secured for the patient and their family as soon as indicated. Palliative care consultation should be sought promptly when the limits of the critical care specialist's experience have been reached. A consult with palliative care may bring several benefits, such as ensuring that all possible interventions have been performed, improving communication between ICU staff and the patient's family, and educating providers about palliative initiatives in the care of dying patients.

Most of the reviewed guidelines agree that the principle of double effect is crucial in justifying the use of high doses of narcotic and sedative medication at the end-of-life. However, the Italian Bioethics Committee questioned the need for the principle of double effect, arguing that there is a lack of conclusive evidence to show that these medications may hasten death when used for palliative means;[18] this last argument requires further investigation. Meanwhile, the clinician's intent to use medications for symptom management should be elucidated by adequate communication, along with appropriate documentation. Intensivists must bear in mind the legal implications of exceeding the maximum dosages of medications needed for symptom control according to their local legislation.[25–28]

This review has some limitations. First, there is a wide variety of search terms relating to terminal care in the ICU. To overcome this limitation, two anesthesiologists and a research librarian were involved in complementing the search terms used. Second, there was heterogeneity in the methodologies of the reviewed sources. Third, most of the recommendations examined were based on ethical principles or drawn from different populations, indicating a lack of high-quality evidence on this matter. Although limited by the methodology of the reviewed sources, this study serves as an extensive compilation of recommendations for pain management in dying, critically ill patients.

In conclusion, our findings allow us to establish points of agreement among international societies in the management of pain at the end-of-life in the ICU, as guided by the ethical principle of providing a dignified death. There is a need to develop quality improvement strategies and to produce evidence-based pain management strategies, as well as to explore the most effective method for pain assessment in the critically ill patient at the end of life and the role of new analgesics and nonpharmacologic measures for pain management in this setting. With the reviewed recommendations, we developed a management algorithm that may improve the care of critically ill dying patients, and we are in the process of its validation.