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，但疼痛是一种常见的，往往是毁灭性的症状控制问题，在生命的尽头。我们已经制定了一个模型，描述了“充分控制疼痛的标准”在门诊肿瘤设置。基于这一理论模型，我们开发了一种方案，该方案正在测试阿片类药物滴定订单，该订单旨在为三个关键的提供者行为提供明确的指导：（1）疼痛评估，（2）生成治疗计划，以及（3）将治疗计划传达给患者。使用类似的医嘱单可能会提高临终关怀环境中的疼痛控制;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特的，而且在很大程度上未经调查。此外，当前临床方案对患者和护理人员造成的负担对于临终关怀环境来说是过度的，并且主要终点不适合终末患者人群。可能影响疼痛结局和/或需要改变临床方案的临终关怀特定因素包括：（1）护理人员的作用日益增加，（2）转向家庭护理，（3）引入临终关怀人员作为医疗保健团队的一部分，（4）初级保健团队的作用日益减少，（5）疾病过程的医疗并发症。因此，修改的理论模型，阿片类药物滴定订单，和协议，将是必要的，以测试这种干预在临终关怀人口。使用混合方法的方法，我们建议确定的独特需求和障碍，疼痛控制在临终关怀设置确定的关键利益相关者（患者，护理人员，临终关怀工作人员和转诊医生）。基于这些数据，我们将修改理论模型，订单和协议。一旦修改完成，我们将进行一项试点研究，以评估在门诊临终关怀设置的可行性，实用性和有效性的订单。

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.