Julie Griffie

Assessment and treatment of discomfort for people with late-stage dementia

People with dementia have often been excluded from pain studies. However, there is evidence supporting that people with dementia experience frequent pain, often poorly assessed and undertreated, and that the etiology for pain descriptions is poorly documented. The Assessment of Discomfort in Dementia (ADD) Protocol is designed to: a) more accurately assess discomfort in people with dementia who can no longer verbally describe physical pain or affective discomfort; b) more accurately and thoroughly treat physical pain and affective discomfort; and c) decrease inappropriate use of psychotropic medication. The use of the ADD Protocol was studies with a convenience sample of 104 residents of long-term care with end-stage dementia. Use of the ADD Protocol was associated with a significant decrease in discomfort (t = 6.56, p = 0.000). The most frequently seen behavioral symptoms associated with discomfort were tense body language, sad facial expression, fidgeting, perseverant verbalizations, and verbal outburts. The ADD Protocol was also associated with a significant increase in the use of scheduled analgesics and non-pharmacological comfort interventions. The protocol was not associated with an increase in the use of prn analgesics or with prn or scheduled psychotropics. This study has provided some support for the notion that the needs of people with significant dementia can be discerned and treated.

Building an Institutional Commitment to Pain Management in Long-Term Care Facilities

This report reviews the development, implementation and findings of an inter-institutional study directed to the goal of making pain management an institutional priority in Wisconsin long-term care facilities. A total of 87 facilities were recruited in two training cohorts. Each facility identified a team of individuals, with responsibility and authority for care policies within their institution, to participate in four structured educational programs. Each team completed an Action Plan, structured around 14 national practice indicators of an institutional commitment to pain management. At baseline, 14% of facilities had > 51% of the indicators in place; at conclusion 74% of facilities had > 51% of indicators in place. This education project was successful across training cohorts at implementing critical pain management target indicators.

A role model program to promote institutional changes for management of acute and cancer pain

This report describes an 18-month project to make acute and cancer pain management an institutional priority in Southeastern Wisconsin health-care facilities. Facility-based teams, each of which included a nurse in a leadership position, were recruited to participate in a project based on the Cancer Pain Role Model Program. The project was conducted in three stages: (a) a 1-day conference focusing on basic pain management issues and clinical standards, (b) a preceptorship at the Medical College of Wisconsin, and (c) a follow-up conference focusing on institutional change. Participants completed an Action Plan, outlining activities aimed at changing practice in their facility. Participants from 17 of the 32 participating facilities partially or completely met their Action Plan goals. Lack of ongoing facility commitment, staff turnover and facility closures were cited as reasons for failure to meet goals. Nurses in key positions, provided with strong institutional commitment and given suitable educational training and nurturing, are ideally suited to help facilitate changes in institutional pain practices.

Integration of palliative medicine at the Medical College of Wisconsin 1990-1996.

Palliative medicine is an emerging world-wide discipline. This article describes efforts at the Medical College of Wisconsin (MCW) to develop programs to enhance palliative medicine education and clinical care. New courses, seminars and clinical programs have been developed. Education and clinical care activities since 1990 have included a required course for second-year medical students, clinical electives for third- and fourth-year medical students, a clinical palliative care consultation service, a palliative care seminar series designed for housestaff, and a nurse preceptorship program. Palliative medicine activities have included both the academic medical center and community health agencies. MCW has integrated palliative medicine into its academic environment so that trainees at all education levels now have opportunities for didactic and clinical end-of-life care education.

The Palliative Care Consultation Service of the Medical College of Wisconsin.

Palliative care has not become a routine aspect of US academic medicine due to lack of reimbursement for clinical services, little research funding, and the perception that care for the terminally ill is not important in academic medical centers. This article describes the clinical activities of a new Palliative Care Consultation Service (PCS) for inpatients and outpatients, which was started at the Medical College of Wisconsin in April 1993. The goals of the PCS are to provide symptom control, assist with end-of-life decision making, and serve as a resource for appropriate discharge planning for all dying patients, not only those with cancer. Since its inception, an average of five consultations per week have been seen. Pain and end-of-life decisions were the most frequent reasons for consultation. Thirteen different clinical services consulted the PCS, most commonly internal medicine and oncology. Cancer and acquired immunodeficiency syndrome (AIDS) were the most frequent diagnoses. The PCS has also been used as a resource for assessment of inpatients with chronic nonmalignant pain who were believed to be drug addicts. The PCS has received widespread acceptance by the medical, nursing, and support staffs. The clinical and educational role of a dedicated palliative care service in academic medicine is discussed.

Palliative medicine nurse preceptorship at the Medical College of Wisconsin

This article describes a 3-day nurse preceptorship education program in cancer pain and palliative medicine at the Medical College of Wisconsin (MCW). The program includes experiential and didactic information skills development, and assistance with planning for institutional change in the delivery of health care services. The education program is centered around five teaching modules: pain, nonpain symptoms, hospice, nursing professional issues, and palliative care. Evaluation data from a recent cohort of 23 nurses demonstrate that learning and personal objectives were met to a high degree of satisfaction.