Hospice Pain Control: Developing an Opioid Order Sheet

描述(由申请人提供)：尽管有有效的药物制剂可用，但疼痛是一种常见的、往往是毁灭性的临终症状控制问题。我们已经制定了一个模型，该模型描述了门诊肿瘤学环境中“充分疼痛控制的标准”。基于这一理论模型，我们开发了一种测试阿片类药物滴定顺序表的方案，其结构为三个关键提供者行为提供了明确的方向：(1)疼痛评估，(2)治疗计划的生成，以及(3)治疗计划与患者的沟通。在临终关怀环境中使用类似的订单可能会加强疼痛控制；然而，临终关怀环境中充分控制疼痛的需求和潜在障碍是独一无二的，基本上没有进行过调查。此外，目前的临床方案对患者和护理人员施加的负担对于临终关怀环境来说是过重的，主要终点不适合晚期患者群体。临终关怀可能影响疼痛结局和/或需要修改临床方案的具体因素包括：(1)护理人员的作用增加，(2)转向居家护理，(3)引入临终关怀工作人员作为卫生保健团队的一部分，(4)初级保健团队的作用减少，以及(5)疾病过程中的医疗并发症。因此，有必要修改理论模型、阿片类药物滴定顺序表和方案，以便在临终关怀人群中测试这种干预。使用混合方法，我们建议确定由关键利益相关者(患者、护理人员、临终关怀人员和转诊医生)确定的临终关怀环境中疼痛控制的独特需求和障碍。根据这些数据，我们将对理论模型、订单和协议进行修改。一旦进行了修改，我们将进行一项试点研究，以评估医嘱单在门诊临终关怀环境中的可行性、实用性和有效性。

DESCRIPTION (provided by applicant): Despite the availability of effective pharmaceutical agents, pain is a common and often devastating symptom control problem at end-of-life. We have formulated a model that describes "criteria for adequate pain control" in the outpatient oncology setting. Based on this theoretical model, we have developed a protocol which is testing an opioid titration order sheet structured to provide clear direction for three critical provider behaviors: (1) pain assessment, (2) generation of a treatment plan, and (3) communication of the treatment plan to the patient. The use of a similar order sheet may enhance pain control in the hospice setting; however, the needs and potential barriers to adequate pain control within the hospice setting are unique and largely uninvestigated. Furthermore, the burden imposed by the current clinical protocol on patients and caregivers is excessive for the hospice setting and the primary endpoints are not appropriate to the terminal patient population. Hospice specific factors which may affect pain outcome and/or require alterations in the clinical protocol include: (1) the increasing role of caregivers, (2) the shift to home based care, (3) introduction of hospice staff as part of the health care team, (4) the decreasing role of the primary care team and (5) medical complications of the disease process. Thus, modification of the theoretical model, the opioid titration order sheet, and the protocol, will be necessary in order to test this intervention in the hospice population. Using a mixed methods approach, we propose to identify the unique needs and barriers for pain control in the hospice setting as identified by key stakeholders (patients, caregivers, hospice staff and referring physicians). Based on these data we will modify the theoretical model, the order sheet and the protocol. Once the modifications lave been made, we will conduct a pilot study to assess feasibility, utility and efficacy of the order sheet in the outpatient hospice setting.