<http://www.w3.org/2009/08/skos-reference/skos.html#note>
"Report on Pain Assessment for Palliative Care Patients Tenny Bache,\u00AA Aja Egglestone,\u00AA Neda Khoshnood,\u00AA &amp; Kelly Soros\u00AA \u00AAUBC School of Nursing Program 2012, Vancouver, BC Vancouver General Hospital: Nicole Wikjord UBC faculty partner: Helga Marshall Purpose: The purpose of this project is to provide evidence-based recommendations on specific pain measurement tools and flow sheets that would be appropriate for use in the Acute Palliative Care Unit at Vancouver General Hospital (VGH APCU). Through research and analysis of various pain assessment tools, consideration of peer-reviewed articles, performing a needs assessment of the unit and benchmarking with various health care facilities across BC and Canada, we have identified the effectiveness and usefulness of various pain assessment tools in the acute palliative care setting. Overview: We have identified and compiled a table of 22 pain measurement and assessment tools. A brief description of each tool is provided as well as the strengths, weaknesses, ease of administration, validity, and validity specific to palliative. Additionally, a needs assessment was conducted in order to address the gaps in the current pain assessment tool used at VGH APCU. This was achieved by performing chart reviews, interviews and questionnaires. Collaborative benchmarking of current palliative pain assessment tools from various health authorities (Fraser Health Authority, Providence Health, Calgary Health Region, Nova Scotia Health and the United Kingdom) is also provided. A table has been included that lists the tools utilized in each health authority along with their respective features, benefits, limitations and remarks. It is our hope that this project will facilitate the discussion around the implementation of new standardized pain measurement tools and documentation at VGH APCU. Background: Research shows that pain assessment in a clinical setting requires a systematic approach (Weissman, Griffie, Muchka, &amp; Matson, 2000). This will avoid unnecessary complex assessment methods, ensure efficient use of resources, minimize the number of instruments used, create standardization of the tools, improve patient assessment and care, and improve documentation and communication between health care providers (Weissman et al., 2000). However, any systematic assessment tool must be considered in the context of the clients\u2019 current situation, and variances in sources and perceptions of pain need to be addressed. Components of assessment tools which are most relevant for the clinician and the patient may vary along the disease trajectory and between patients (Kaasa et al., 2008). Therefore, selecting a flexible tool (eg. a tool that can be administered via a combination of self-reports, caregiver reports, and/or behavioural indications) may be the most efficient option particularly for those unable to verbally express pain. Literature Analysis: Health care professionals, patients, and families can use pain assessment tools to UBC Nursing Student Journal, Vol.1, Issue 1. 17gather data through patient self-reporting and behavioural observation. If possible, self-reporting should be the primary source of information when completing a pain assessment as it \u201Cis still the most reliable indicator of pain\u201D (Jaggar &amp; Holdcraft, 2005, p. 81). The exception to self-reporting is with non-verbal, non-cognisant persons. For these populations, behavioural observations validated by family and caregivers should be the primary source of information for a pain assessment. Observational assessments can also be used routinely in order to reduce the patient burden of routine hourly pain checks.   The pain assessment tools listed are either unidimensional or multidimensional. Unidimensional tools such as the Numerical Rating Scale (NRS), Verbal Rating Scale (VRS), and Verbal Analog Scale (VAS) are highly sensitive in assessing specific features (ie. pain intensity), but rarely address the other components of pain (Katz &amp; Melzack, 1999). Unidimensional tools are quick to administer, easy to understand, and have been widely used and validated. A major criticism of these rating scales is that they \u201Cdo not actually provide ration-level scaling of pain. Therefore, if a patient\u2019s pain is reduced from 8 to 4 after treatment, it cannot be inferred that she or he has experienced a 50% reduction in pain\u201D (Fillingham, 2005, p. 72). Multidimensional tools such as the McGill Pain Questionnaire (MPQ), Brief Pain Inventory (BPI), and Memorial Symptom Assessment Scale (MSAS) can be highly sensitive at assessing all of the common components of the pain experience (physical, psychological, social, cultural and spiritual). Many multidimensional tools have also been validated across cultures and languages and demonstrate a high level of consistency (Jagger &amp; Holdcroft, 2005). Furthermore, because pain is \u201Can unpleasant sensory and emotional experience associated with actual or potential tissue damage\u201D (IASP, 2011), a full assessment of pain therefore requires a multidimensional approach for pain evaluation (Jaggar &amp; Holdcroft, 2005). However, multidimensional assessment tools require more time (from the patient and the person performing the assessment) than unidimensional scales and tend be harder to learn to administer and score, limiting their routine use in clinical settings. Multidimensional Palliative Pain Assessment Tool: The Edmonton Symptom Assessment System (ESAS) is a valid and reliable assessment tool to assist in the assessment of nine common symptoms experienced by cancer patients (Watanabe et al., 2011).  The original tool was developed by the Regional Palliative Care Program, Capital Health in Edmonton, Alberta, and is one of the key assessment tools used in the Palliative Care Integration Project initiated by Queen's University (2012).  The ESAS is designed to assist in the assessment of: pain, tiredness, nausea, depression, anxiety, drowsiness, appetite, well being, and shortness of breath. One blank scale is available for patients to use to assess an \u201Cother problem\u201D as needed.  The severity at the time of assessment of each symptom is rated from 0 to 10 on a numerical scale; with 0 meaning that the symptom is absent and 10 that it is the worst possible severity. The ESAS was designed so that the patient, or his/her family caregiver, could self-administer UBC Nursing Student Journal, Vol.1, Issue 1. 18the tool, and ideally, the patient and family should be taught how to complete the scale. It is the patient\u2019s opinion of the severity of the symptoms that is the gold standard for symptom assessment, and the ESAS provides a clinical profile of symptom severity over time. It provides a context within which symptoms can be understood. However, it is not a complete assessment in itself and must be used as one part of a holistic clinical assessment. A Needs Assessment: A needs assessment is a critical component in understanding and addressing concerns expressed by the staff, clinicians, and management surrounding pain assessment at VGH APCU. To analyse the current pain assessment tool in use (a  flowsheet used VGH-wide which was developed originally for use in acute medicine); chart reviews, questionnaires, and clinician interviews were conducted to identify possible gaps, effectiveness, accuracy and adherence to using the tool. After careful review of charts and documentation records on the APCU, it was evident the major use for the pain assessment flow sheet was as a medication administration record.  Specifically, the scheduled and breakthrough pain medications and doses were recorded on the flow sheet, while subjective pain data was rarely recorded. This type of documentation does not provide a  full clinical picture of client circumstances prior to medication administration, raising a number of issues related to documentation practice standards as put forth by the College of Registered Nurses of British Columbia (CRNBC, 2012) such as communication, safe and appropriate nursing care, and professional and legal practice standards After a chart review, seventeen questionnaires were administered to staff including registered nurses, licensed practical nurses, medical residents, and physicians. The questions investigated the perspectives of the staff surrounding: (1)  the usefulness of the flow sheet in use,  (2) information that should be be added or removed, and (3) concerns addressing gaps in the current pain tool and documentation method. The data collected from the interviews and questionnaires were congruent with the information collected from the chart and documentation review. Several reasons suggested by staff members provide a rationale for the method of documentation evident in the  chart review. First and foremost, staff nurses and physicians appreciated that the current tool allowed a clear visualization of the trends in medication administration over a period of time. Second, respondents reported that staff were reluctant to use the tool regularly because they felt that due to the patient burden incurred during assessment, clients could possibly be annoyed or disturbed by self-report pain on a frequent basis (eg. every one hour). Recognizing and understanding the patients\u2019 perspective is an important issue to address, because in order to achieve optimal health outcomes, patients need to be active partners in their care. We suggest that further research be carried out to determine patient satisfaction with participating in frequent pain assessments at VGH APCU. Thirdly, all staff members indicated that including a section for respiratory distress medications would be helpful because currently there is no space to write it on the flow sheet, so they were recording these medications on the flow sheet in a section designated for pain intensity, respiration rate, sedation UBC Nursing Student Journal, Vol.1, Issue 1. 19score, and side effects. Forthly, respondents felt that the addition of a section indicating the 24 hour medication totals would be beneficial. Overall, the staff members were pleased with the current pain assessment flow sheet and found it useful in monitoring pain control, titrated medications, and medication trends over time. These interviews and questionnaires were crucial to understanding the perspective of the staff, which will help select a relevant and appropriate pain assessment tool and documentation flow sheet, and improve clinician adherence to utilizing the tool and improving pain- related documentation in the future. Benchmarking: Part of this project involved contacting a number of local and national health authorities to determine what kinds of documentation and pain assessment tools are used in other jurisdictions. The following health authorities were contacted: Providence Health Care, Fraser Health Authority, Calgary Health Region, Capital Health (Nova Scotia), and NHS in the United Kingdom. Victoria Hospice was contacted regarding this project however we received no reply.  All health authorities\u2019 documentation was reviewed and analysed for features, benefits, limitations and remarks (see the benchmarking table for details).  The remark section includes information given from the various health authority contacts regarding the subjective usefulness and features of the documentation. The conclusion from the collaborative benchmarking indicates that while no health authority uses the same pain assessment tool, there are several contributing factors which determine an effective and efficient tool.  Such factors include simplicity and efficiency for both health care provider and patient.  Additionally, in order to achieve optimal outcomes, a visualization of the trends over time and the various interventions used should be illustrated. Recommendations: Based on our literature analysis, needs assessment and benchmarking, we recommend that (1) a comprehensive, multidimensional tool be administered upon admission to VGH APCU, while (2) continuing to use a unidimensional tool (eg. NRS) for assessing patients\u2019 pain prior to any intervention. (3) A comprehensive multidimensional tool such as the Edmonton Symptom Assessment System should be administered once per shift (or per 24 hours) to assess various factors which may contribute to the pain and discomfort of palliative patients. Finally, as the disease trajectory, goals, and needs of the palliative patient changes, (4) pain assessment tools need to be modified and individualized.   Future Implications: We recommend the design of a draft pain assessment tool which is unique to the VGH APCU, and implement it as a trial study and then evaluate its effectiveness among staff and patients on the unit. We also suggest that further research be carried out to determine patient satisfaction with participating in frequent pain assessments. References 1. Abbey J, Piller N, De Bellis A, Esterman A, Parker D, Giles L, Lowcay B. (2004). The Abbey pain scale: a 1-minute numerical indicator for people with end-stage dementia. Int J Palliat Nurs. Jan; 10(1):6-13. 2. American Geriatrics Society Panel Guidelines on Persistent Pain in Older Persons. Journal of the  American Geriatrics  Association. 50 : S205-S224, 2002. Accessed at:  http://www.americangeriatrics.org/ UBC Nursing Student Journal, Vol.1, Issue 1. 203. Armstrong, T.S., Gning, I., Mendoza, T.R., Vera-Bolanos, E., Gilbert, M.R., Rhines, L.D, Weinberg, J.S., Sanchez-Williams, G., Levin, V., Burton, A.W., &amp; Cleeland, C. (2010).  Reliability and validity of the M.D. Anderson Symptom Inventory-Spine Tumor  Module. Department of Integrative Care. 4. Australian Pain Society. (2005). Pain in Residential Aged Care Facilities: Management Strategies. Accessed at: http://www.apsoc.org.au/owner/files/9e2c2n.pdf 5. Scott J, Huskinsson EC. Graphic representation of pain. Pain 1976; 2:175\u2013184. 6. Bouhassira D, Attal N, Fermanian J, Alchaar H, Gautron M, Masquelier E, Rostaing S, Lanteri-Minet M, Bruera E, Kuehn N, Miller MJ, Selmser P, Macmillan K. (1991). The Edmonton Symptom Assessment System (ESAS): a simple method for the assessment of palliative care patients. J Palliat Care. 7:6-9. 7. Bruera E, Kuehn N, Miller MJ, Selmser P, Macmillan K. (1991). The Edmonton Symptom Assessment System (ESAS): a simple method for the assessment of palliative care patients. J Palliat Care. Summer;7(2):6\u20139. [PubMed] 8. Caraceni A, Cherny N, Fainsinger R, Kaasa S, Poulain P, Radbruch L, De Conno F. (2002). measurement tools and methods in clinical research in palliative care: recommendations of an Expert Working Group of the European Association of Palliative Care. J Pain Symptom Manage. 23: 239-255 9. Centre for Gerontology and Health Care Research, Brown University. (2004). TIME: Toolkit of Instruments to Measure End- of-Life Care. Accessed at: http://www.chcr.brown.edu/pcoc/toolkit.htm 10. Chang VT, Hwang SS, Kasimis B, Thaler HT. (2004) Shorter symptom assessment instruments: the Condensed Memorial Symptom Assessment Scale (CMSAS). Cancer Invest. 22(4):526-36. 11. Chang VT, Hwang SS, Feuerman M, Kasimis BS, Thaler HT. (2000). The memorial symptom assessment scale short form (MSAS-SF). Cancer. Sep 1;89(5):1162-71. 12. Cleeland CS, Mendoza TR, Wang XS, Chou C, Harle MT, Morrissey M, Engstrom MC. (2000). Assessing symptom distress in cancer patients: the M.D. Anderson Symptom Inventory. Cancer. Oct 1;89(7):1634-46. Cleeland, C. S. (1989). Measurement of pain by subjective report. In C. R. Chapman &amp; J. D. Loeser (Eds.), Advances in pain  research and therapy: Issues in pain measurement. Vol. 12, pp. 391-403. 13. Cleeland CS. Pain assessment in cancer. In: Osoba D, ed. Effect of Cancer on Quality of Life. Boca Raton, FL: CRC Press, Inc.; 1991:293\u2013305. 14. College of Registered Nurses of British Columbia. (2012). Practice Standard for Registered Nurses and Nurse Practitioners:  Documentation. Accessed at: https://www.crnbc.ca/Standards/Lists/StandardResources/334DocumentationPracStd.pdf 15. Collin E, Grisart J, Boureau F. (2004). Development and validation of the Neuropathic Pain Symptom Inventory. Pain. Apr;108(3):248-57. 16. Davies, T. A., Chadury, Y., Williams, A. C. H. (2000) Simple pain rating scales hide complex idiosyncratic meanings. Pain. 85, 457-463. 17. Doctor, J. N., Slater, M. A., &amp; Atkinson, J. H. (1995). The descriptor differential scale of pain intensity: an evaluation of item and scale properties. Pain, 61 (1995) 251-260 251  18. Downie WW, Leatham PA, Rhind VM, Wright V, Branco JA, Anderson JA. (1978). Studies with pain rating scales. Ann Rheum Dis. 37:378-381. 19. Duggleby, W. (2002). The language of pain at the end of life. Pain Management Nursing, 3(4), 154-160. 20. Ellershaw JE, Wilkinson S (2003). Care of the Dying: A Pathway to Excellence. Oxford: Oxford University Press 21. Fenwick, C., &amp; Stevens, J. (2004). Post operative pain experiences of central Australian aboriginal women. What do we understand? Australian Journal of Rural Health. 2(1), 22-27. 22. Ferrell, B.R., &amp; Coyle, N. (2010) Oxford textbook of Palliative Nursing. 23. Fillingham, R. B. (2005). Pain Measurement in Humans. In Holdcroft, A., &amp; Jaggar, S. I. Eds. Core Topics in Pain. Cambridge: Cambridge University Press. 24. Frampton &amp; Hughes-Webb (2011). The Measurement of Pain. Clinical Oncology. 23, 381-386 25. Franco de Conno, Augusto Caraceni, Alessio Gamba, Luigi Mariani, Antonello Abbattista, Cinzia Brunelli, Angela La Mura, Vittorio Vacntafridda. (1994). Pain measurement in cancer patients: a comparison of six methods. Pain. Vol 57, Issue 2, Pages 161-166. 26. Gagliese L, Weizblit N, Ellis W, Chan VW. (2005). The measurement of postoperative pain: a comparison of intensity scales in UBC Nursing Student Journal, Vol.1, Issue 1. 21younger and older surgical patients.Pain. 2005 Oct;117(3):412-20. 27. Galer BS, Jensen MP.(1997). Development and preliminary validation of a pain measure specific to  neuropathic pain: the Neuropathic Pain Scale. Neurology. Feb;48(2):332-8 28. Gagliesea L, Katz J. (2003). Age differences in postoperative pain are scale dependent: a comparison of measures of pain intensity and quality in younger and older surgical patients. Pain. 103:11\u201320. 29. Gracely, R.H. and Kwilosz, D.M. (1988). The descriptor differential scale: applying psychophysical principles to clinical pain assessment. Pain 35, pp. 279\u2013288. 30. Hall, E., Terezhalmy, D.D., &amp; Pelleu, G. (2005). A set of descriptors for the diagnosis of dental pain syndromes. Naval Dental School. 31. Herr KA, Garand L. (2001). Assessment and Measurement of  Pain in Older Adults. In Ferrell B, Ed. Pain management in  the elderly. Clinics in geriatric medicine: WB Saunders Company. 32. Herr, K., Coyne, P., Manworren, R., McCaffery, M., Pelosi, J., &amp; Wild, L. (2006). Pain Assessment in the Nonverbal Patient:  Position Statement with Clinical Practice Recommendations. The American Society for Pain Management Nursing. 33. Hjermstad MJ, Gibbins J, Haugen DF, et al. (2008). Pain assessment tools in palliative care: an urgent need for consensus. Palliat Med. 22:895-903. 34. IASP. (1994). Part III: Pain Terms, A Current List with Definitions and Notes on Usage. Classification of Chronic Pain, Second Edition. Accessed online at:http://www.iasp-pain.org/AM/Template.cfm?Section=Pain_Defi...isplay.cfm&amp;ContentID=1728 35. Jensen, M.P., Friedmen, M., Bonzo, D., &amp; Richards, P. (2006). The validity of the neuropathic pain scale for assessing diabetic  neuropathic pain in a clinical trial. Department of Rehabilitation Medicine. 36. Joyce CR, Zutshi DW, Hrubes V, Mason RM. Comparison of fixed interval and visual analogue scales for rating chronic pain. Eur J Clin Pharmacol. 1975;8:415\u2013420. 37. Jaggar, S. I. &amp; Holdcroft, A. (2005). Principles of pain evaluation. In Holdcroft, A., &amp; Jaggar, S. I. Eds. Core Topics in Pain. Cambridge: Cambridge University Press. 38. Jensen MP, Karoly P. (2003). Self-report scales and procedures for assessing pain in adults. In: Turk DC, Melzack R (Eds). Handbook of Pain Assessment. New York: Guilford Press, pp 15\u201334. 39. Jensen MP. (2003). The validity and reliability of pain measures in adults with cancer. J Pain. 4:2\u201321 40. Katz, J., &amp; Melzack, R. (1999). Measurement of pain. Surg. Clin. North Am., 79, p. 239-252. 41. Keller, S., Bann, C.M., Dodd, S.L., Schein, L., Mendoza, T.R., &amp; Cleeland, C.S. (2004). Validity of the brief pain inventory for use  in documenting the outcomes of patients with noncancer pain. American Institute for Research. 42. Keller, S., Bann, C.M., Dodd, S.L., Schein, J., Mendoza, T.R., Cleeland, C.S. (2004). Validity of the Brief Pain Inventory for use in documenting the outcomes of patients with noncancer pain. Clinical Journal of Pain, 20(5), 309-318. 43. Manias, E., Botti, M., &amp; Bucknall, T. (2002). Observation of pain assessment and management -- the complexities of clinical practice. Journal Of Clinical Nursing, 11(6), 724-733. 44. McCorkle R. (1987). The measurement of symptom distress. Seminars in Oncology Nursing. 3:248-56. 45. McLafferty, E., &amp; Farley, A. (2008). Assessing pain in patients. Nursing Standard, 22(25), 42- 46. 46. Mercadante, S. (2009). Tools for identifying cancer pain of predominantly neuropathic origin and opioid responsiveness in cancer patients. The journal of pain. 10(6), 594-601 47. Merkel, S. I., Voepel-Lewis, T., Shayevitz, J. R., &amp; Malviya, S. (1997). The FLACC: A behavioral scale for scoring postoperative pain in young children. Pediatric Nursing, 23(3), 293\u2013297. 48. Melzack R. (1975). The McGill Pain Questionnaire: Major properties and scoring methods. Pain. 1: 277-299. 49. Moro C, Brunelli C, Miccinesi G, Fallai M, Morino P, Piazza M, Labianca R, Ripamonti C. (2005).  Edmonton symptom assessment scale: Italian validation in two palliative care settings. Support Care Cancer. Jun 4. 50. Odhner M, Wegman D, Freeland N, Steinmetz A, Ingersoll G. (2003). Assessing pain control in nonverbal critically ill adults. Dimensions of Critical Care Nursing. 22:260\u2013267. 51. Portenoy, RK, Thaler HT, Kornblith AB, Lepore JM, Friedlander-Klar H, Kiyasu E, Sobel K, Coyle N, Kemeny N, Norton L. (1994). The Memorial Symptom Assessment Scale: an instrument for the evaluation of symptom prevalence, characteristics and distress. European Journal of Cancer. 30A(9):1326. 52. Queen's University School of Medicine. (2012). Palliative Care Integration Project. Accessed at: UBC Nursing Student Journal, Vol.1, Issue 1. 22http://meds.queensu.ca/palliativecare/clinical_resources_-_intro 53. Rees E, Hardy J, Ling J, Bradley K, A\u2019Hern R. (1998). The use of the Edmonton Symptom Assessment Scale (ESAS) within a palliative care unit in the UK. Palliative Medicine. 12:75-82. 54. Renee C.B. Manworren, Linda S. Hynan. (2003). Clinical Validation of FLACC: Preverbal Patient Pain Scale. Pediatric Nursing. 29(2) 55. Solman, R., Wruble, A., Rosen, G., &amp; Rom, M. (2006). Determination of clinically meaningful level of pain reduction in patients experiencing acute postoperative pain. Pain Management Nursing, 7(4), 153-158 56. Wallen GR, Wittink HM, Berger A, Carr DB. (2008). Palliative care outcome measures: translating research into practice. In: Wittink HM, Carr DB, eds. Pain Management: Evidence, Outcomes, and Quality of Life. A Sourcebook. London: Elsevier, 377\u2013 405. 57. Wang XS, Cleeland CS. (2008). Outcomes measurement in cancer pain. In: Pain Management: Evidence, Outcomes, and  Quality of Life. A Sourcebook -- Wittink HM, Carr DB, eds. London: Elsevier. 361-76. 58. Warden, V., Hurley, A.C., &amp; Volicer, L. (2003). Development and psychometric evaluation of the pain assessment in advanced dementia (PAINAD) Scale. Journal of the American Medical Directors Association, 4(1), 9-15. 59. Wong, D. and Baker, C.(1988). Pain in children: comparison of assessment scales, Pediatric Nursing, 14(1):9-17. 60. Watanabe SM, Nekolaichuk C, Beaumont C, Johnson L, Myers J, Strasser F. (2011). A multi-centre comparison of two numerical versions of the Edmonton Symptom Assessment System in palliative care patients J Pain Symptom Manage. 41:456- 468. 61. Webber, K. &amp; Davies, A.N. (2011). Validity of the memorial symptom assessment scale-short form psychological subscales in  advanced cancer patients. Royal Marsden NHS Hospital Trust 62. Weissman DE, Griffie J, Muchka S, Matson S. Building an  institutional commitment to pain management in longterm care facilities. J Pain Symptom Manage 2000; 35 20 1. In: The Australian Pain Society. (2005). Pain in Residential Aged Care  Facilities: Management Strategies. Accessed at: http://www.apsoc.org.au/owner/files/9e2c2n.pdf 63. Yadeau, J.T., Liu, S.S., Rade, M.C., Marcello, D., &amp; Liguori, G.A. (2011). Performance characteristic and validation of the  opioid-related symptom distress scalre for evaluation of analgesic side effects after orthopaedic surgery.  Department of anaesthesiology. 64. Zinke, J.L., Lam, C.S., Harden, R.N., &amp; Fogg, L. (2010). Examining the cross-cultural validity of the English short-from McGill  pain Questionnaire using the matched moderated regression methodology. Northwestern University. UBC Nursing Student Journal, Vol.1, Issue 1. 23 Report on Pain Assessment for Palliative Care Patients Tenny Bache,\u00AA Aja Egglestone,\u00AA Neda Khoshnood,\u00AA &amp; Kelly Soros\u00AA \u00AAUBC School of Nursing Program 2012, Vancouver, BC Vancouver General Hospital: Nicole Wikjord UBC faculty partner: Helga Marshall Purpose: The purpose of this project is to provide evidence-based recommendations on specific pain measurement tools and flow sheets that would be appropriate for use in the Acute Palliative Care Unit at Vancouver General Hospital (VGH APCU). Through research and analysis of various pain assessment tools, consideration of peer-reviewed articles, performing a needs assessment of the unit and benchmarking with various health care facilities across BC and Canada, we have identified the effectiveness and usefulness of various pain assessment tools in the acute palliative care setting. Overview: We have identified and compiled a table of 22 pain measurement and assessment tools. A brief description of each tool is provided as well as the strengths, weaknesses, ease of administration, validity, and validity specific to palliative. Additionally, a needs assessment was conducted in order to address the gaps in the current pain assessment tool used at VGH APCU. This was achieved by performing chart reviews, interviews and questionnaires. Collaborative benchmarking of current palliative pain assessment tools from various health authorities (Fraser Health Authority, Providence Health, Calgary Health Region, Nova Scotia Health and the United Kingdom) is also provided. A table has been included that lists the tools utilized in each health authority along with their respective features, benefits, limitations and remarks. It is our hope that this project will facilitate the discussion around the implementation of new standardized pain measurement tools and documentation at VGH APCU. Background: Research shows that pain assessment in a clinical setting requires a systematic approach (Weissman, Griffie, Muchka, &amp; Matson, 2000). This will avoid unnecessary complex assessment methods, ensure efficient use of resources, minimize the number of instruments used, create standardization of the tools, improve patient assessment and care, and improve documentation and communication between health care providers (Weissman et al., 2000). However, any systematic assessment tool must be considered in the context of the clients\u2019 current situation, and variances in sources and perceptions of pain need to be addressed. Components of assessment tools which are most relevant for the clinician and the patient may vary along the disease trajectory and between patients (Kaasa et al., 2008). Therefore, selecting a flexible tool (eg. a tool that can be administered via a combination of self-reports, caregiver reports, and/or behavioural indications) may be the most efficient option particularly for those unable to verbally express pain. Literature Analysis: Health care professionals, patients, and families can use pain assessment tools to UBC Nursing Student Journal, Vol.1, Issue 1. 17gather data through patient self-reporting and behavioural observation. If possible, self-reporting should be the primary source of information when completing a pain assessment as it \u201Cis still the most reliable indicator of pain\u201D (Jaggar &amp; Holdcraft, 2005, p. 81). The exception to self-reporting is with non-verbal, non-cognisant persons. For these populations, behavioural observations validated by family and caregivers should be the primary source of information for a pain assessment. Observational assessments can also be used routinely in order to reduce the patient burden of routine hourly pain checks.   The pain assessment tools listed are either unidimensional or multidimensional. Unidimensional tools such as the Numerical Rating Scale (NRS), Verbal Rating Scale (VRS), and Verbal Analog Scale (VAS) are highly sensitive in assessing specific features (ie. pain intensity), but rarely address the other components of pain (Katz &amp; Melzack, 1999). Unidimensional tools are quick to administer, easy to understand, and have been widely used and validated. A major criticism of these rating scales is that they \u201Cdo not actually provide ration-level scaling of pain. Therefore, if a patient\u2019s pain is reduced from 8 to 4 after treatment, it cannot be inferred that she or he has experienced a 50% reduction in pain\u201D (Fillingham, 2005, p. 72). Multidimensional tools such as the McGill Pain Questionnaire (MPQ), Brief Pain Inventory (BPI), and Memorial Symptom Assessment Scale (MSAS) can be highly sensitive at assessing all of the common components of the pain experience (physical, psychological, social, cultural and spiritual). Many multidimensional tools have also been validated across cultures and languages and demonstrate a high level of consistency (Jagger &amp; Holdcroft, 2005). Furthermore, because pain is \u201Can unpleasant sensory and emotional experience associated with actual or potential tissue damage\u201D (IASP, 2011), a full assessment of pain therefore requires a multidimensional approach for pain evaluation (Jaggar &amp; Holdcroft, 2005). However, multidimensional assessment tools require more time (from the patient and the person performing the assessment) than unidimensional scales and tend be harder to learn to administer and score, limiting their routine use in clinical settings. Multidimensional Palliative Pain Assessment Tool: The Edmonton Symptom Assessment System (ESAS) is a valid and reliable assessment tool to assist in the assessment of nine common symptoms experienced by cancer patients (Watanabe et al., 2011).  The original tool was developed by the Regional Palliative Care Program, Capital Health in Edmonton, Alberta, and is one of the key assessment tools used in the Palliative Care Integration Project initiated by Queen's University (2012).  The ESAS is designed to assist in the assessment of: pain, tiredness, nausea, depression, anxiety, drowsiness, appetite, well being, and shortness of breath. One blank scale is available for patients to use to assess an \u201Cother problem\u201D as needed.  The severity at the time of assessment of each symptom is rated from 0 to 10 on a numerical scale; with 0 meaning that the symptom is absent and 10 that it is the worst possible severity. The ESAS was designed so that the patient, or his/her family caregiver, could self-administer UBC Nursing Student Journal, Vol.1, Issue 1. 18the tool, and ideally, the patient and family should be taught how to complete the scale. It is the patient\u2019s opinion of the severity of the symptoms that is the gold standard for symptom assessment, and the ESAS provides a clinical profile of symptom severity over time. It provides a context within which symptoms can be understood. However, it is not a complete assessment in itself and must be used as one part of a holistic clinical assessment. A Needs Assessment: A needs assessment is a critical component in understanding and addressing concerns expressed by the staff, clinicians, and management surrounding pain assessment at VGH APCU. To analyse the current pain assessment tool in use (a  flowsheet used VGH-wide which was developed originally for use in acute medicine); chart reviews, questionnaires, and clinician interviews were conducted to identify possible gaps, effectiveness, accuracy and adherence to using the tool. After careful review of charts and documentation records on the APCU, it was evident the major use for the pain assessment flow sheet was as a medication administration record.  Specifically, the scheduled and breakthrough pain medications and doses were recorded on the flow sheet, while subjective pain data was rarely recorded. This type of documentation does not provide a  full clinical picture of client circumstances prior to medication administration, raising a number of issues related to documentation practice standards as put forth by the College of Registered Nurses of British Columbia (CRNBC, 2012) such as communication, safe and appropriate nursing care, and professional and legal practice standards After a chart review, seventeen questionnaires were administered to staff including registered nurses, licensed practical nurses, medical residents, and physicians. The questions investigated the perspectives of the staff surrounding: (1)  the usefulness of the flow sheet in use,  (2) information that should be be added or removed, and (3) concerns addressing gaps in the current pain tool and documentation method. The data collected from the interviews and questionnaires were congruent with the information collected from the chart and documentation review. Several reasons suggested by staff members provide a rationale for the method of documentation evident in the  chart review. First and foremost, staff nurses and physicians appreciated that the current tool allowed a clear visualization of the trends in medication administration over a period of time. Second, respondents reported that staff were reluctant to use the tool regularly because they felt that due to the patient burden incurred during assessment, clients could possibly be annoyed or disturbed by self-report pain on a frequent basis (eg. every one hour). Recognizing and understanding the patients\u2019 perspective is an important issue to address, because in order to achieve optimal health outcomes, patients need to be active partners in their care. We suggest that further research be carried out to determine patient satisfaction with participating in frequent pain assessments at VGH APCU. Thirdly, all staff members indicated that including a section for respiratory distress medications would be helpful because currently there is no space to write it on the flow sheet, so they were recording these medications on the flow sheet in a section designated for pain intensity, respiration rate, sedation UBC Nursing Student Journal, Vol.1, Issue 1. 19score, and side effects. Forthly, respondents felt that the addition of a section indicating the 24 hour medication totals would be beneficial. Overall, the staff members were pleased with the current pain assessment flow sheet and found it useful in monitoring pain control, titrated medications, and medication trends over time. These interviews and questionnaires were crucial to understanding the perspective of the staff, which will help select a relevant and appropriate pain assessment tool and documentation flow sheet, and improve clinician adherence to utilizing the tool and improving pain- related documentation in the future. Benchmarking: Part of this project involved contacting a number of local and national health authorities to determine what kinds of documentation and pain assessment tools are used in other jurisdictions. The following health authorities were contacted: Providence Health Care, Fraser Health Authority, Calgary Health Region, Capital Health (Nova Scotia), and NHS in the United Kingdom. Victoria Hospice was contacted regarding this project however we received no reply.  All health authorities\u2019 documentation was reviewed and analysed for features, benefits, limitations and remarks (see the benchmarking table for details).  The remark section includes information given from the various health authority contacts regarding the subjective usefulness and features of the documentation. The conclusion from the collaborative benchmarking indicates that while no health authority uses the same pain assessment tool, there are several contributing factors which determine an effective and efficient tool.  Such factors include simplicity and efficiency for both health care provider and patient.  Additionally, in order to achieve optimal outcomes, a visualization of the trends over time and the various interventions used should be illustrated. Recommendations: Based on our literature analysis, needs assessment and benchmarking, we recommend that (1) a comprehensive, multidimensional tool be administered upon admission to VGH APCU, while (2) continuing to use a unidimensional tool (eg. NRS) for assessing patients\u2019 pain prior to any intervention. (3) A comprehensive multidimensional tool such as the Edmonton Symptom Assessment System should be administered once per shift (or per 24 hours) to assess various factors which may contribute to the pain and discomfort of palliative patients. Finally, as the disease trajectory, goals, and needs of the palliative patient changes, (4) pain assessment tools need to be modified and individualized.   Future Implications: We recommend the design of a draft pain assessment tool which is unique to the VGH APCU, and implement it as a trial study and then evaluate its effectiveness among staff and patients on the unit. We also suggest that further research be carried out to determine patient satisfaction with participating in frequent pain assessments. References 1. Abbey J, Piller N, De Bellis A, Esterman A, Parker D, Giles L, Lowcay B. (2004). The Abbey pain scale: a 1-minute numerical indicator for people with end-stage dementia. Int J Palliat Nurs. Jan; 10(1):6-13. 2. American Geriatrics Society Panel Guidelines on Persistent Pain in Older Persons. Journal of the  American Geriatrics  Association. 50 : S205-S224, 2002. Accessed at:  http://www.americangeriatrics.org/ UBC Nursing Student Journal, Vol.1, Issue 1. 203. Armstrong, T.S., Gning, I., Mendoza, T.R., Vera-Bolanos, E., Gilbert, M.R., Rhines, L.D, Weinberg, J.S., Sanchez-Williams, G., Levin, V., Burton, A.W., &amp; Cleeland, C. (2010).  Reliability and validity of the M.D. Anderson Symptom Inventory-Spine Tumor  Module. Department of Integrative Care. 4. Australian Pain Society. (2005). Pain in Residential Aged Care Facilities: Management Strategies. Accessed at: http://www.apsoc.org.au/owner/files/9e2c2n.pdf 5. Scott J, Huskinsson EC. Graphic representation of pain. Pain 1976; 2:175\u2013184. 6. Bouhassira D, Attal N, Fermanian J, Alchaar H, Gautron M, Masquelier E, Rostaing S, Lanteri-Minet M, Bruera E, Kuehn N, Miller MJ, Selmser P, Macmillan K. (1991). The Edmonton Symptom Assessment System (ESAS): a simple method for the assessment of palliative care patients. J Palliat Care. 7:6-9. 7. Bruera E, Kuehn N, Miller MJ, Selmser P, Macmillan K. (1991). The Edmonton Symptom Assessment System (ESAS): a simple method for the assessment of palliative care patients. J Palliat Care. Summer;7(2):6\u20139. [PubMed] 8. Caraceni A, Cherny N, Fainsinger R, Kaasa S, Poulain P, Radbruch L, De Conno F. (2002). measurement tools and methods in clinical research in palliative care: recommendations of an Expert Working Group of the European Association of Palliative Care. J Pain Symptom Manage. 23: 239-255 9. Centre for Gerontology and Health Care Research, Brown University. (2004). TIME: Toolkit of Instruments to Measure End- of-Life Care. Accessed at: http://www.chcr.brown.edu/pcoc/toolkit.htm 10. Chang VT, Hwang SS, Kasimis B, Thaler HT. (2004) Shorter symptom assessment instruments: the Condensed Memorial Symptom Assessment Scale (CMSAS). Cancer Invest. 22(4):526-36. 11. Chang VT, Hwang SS, Feuerman M, Kasimis BS, Thaler HT. (2000). The memorial symptom assessment scale short form (MSAS-SF). Cancer. Sep 1;89(5):1162-71. 12. Cleeland CS, Mendoza TR, Wang XS, Chou C, Harle MT, Morrissey M, Engstrom MC. (2000). Assessing symptom distress in cancer patients: the M.D. Anderson Symptom Inventory. Cancer. Oct 1;89(7):1634-46. Cleeland, C. S. (1989). Measurement of pain by subjective report. In C. R. Chapman &amp; J. D. Loeser (Eds.), Advances in pain  research and therapy: Issues in pain measurement. Vol. 12, pp. 391-403. 13. Cleeland CS. Pain assessment in cancer. In: Osoba D, ed. Effect of Cancer on Quality of Life. Boca Raton, FL: CRC Press, Inc.; 1991:293\u2013305. 14. College of Registered Nurses of British Columbia. (2012). Practice Standard for Registered Nurses and Nurse Practitioners:  Documentation. Accessed at: https://www.crnbc.ca/Standards/Lists/StandardResources/334DocumentationPracStd.pdf 15. Collin E, Grisart J, Boureau F. (2004). Development and validation of the Neuropathic Pain Symptom Inventory. Pain. Apr;108(3):248-57. 16. Davies, T. A., Chadury, Y., Williams, A. C. H. (2000) Simple pain rating scales hide complex idiosyncratic meanings. Pain. 85, 457-463. 17. Doctor, J. N., Slater, M. A., &amp; Atkinson, J. H. (1995). The descriptor differential scale of pain intensity: an evaluation of item and scale properties. Pain, 61 (1995) 251-260 251  18. Downie WW, Leatham PA, Rhind VM, Wright V, Branco JA, Anderson JA. (1978). Studies with pain rating scales. Ann Rheum Dis. 37:378-381. 19. Duggleby, W. (2002). The language of pain at the end of life. Pain Management Nursing, 3(4), 154-160. 20. Ellershaw JE, Wilkinson S (2003). Care of the Dying: A Pathway to Excellence. Oxford: Oxford University Press 21. Fenwick, C., &amp; Stevens, J. (2004). Post operative pain experiences of central Australian aboriginal women. What do we understand? Australian Journal of Rural Health. 2(1), 22-27. 22. Ferrell, B.R., &amp; Coyle, N. (2010) Oxford textbook of Palliative Nursing. 23. Fillingham, R. B. (2005). Pain Measurement in Humans. In Holdcroft, A., &amp; Jaggar, S. I. Eds. Core Topics in Pain. Cambridge: Cambridge University Press. 24. Frampton &amp; Hughes-Webb (2011). The Measurement of Pain. Clinical Oncology. 23, 381-386 25. Franco de Conno, Augusto Caraceni, Alessio Gamba, Luigi Mariani, Antonello Abbattista, Cinzia Brunelli, Angela La Mura, Vittorio Vacntafridda. (1994). Pain measurement in cancer patients: a comparison of six methods. Pain. Vol 57, Issue 2, Pages 161-166. 26. Gagliese L, Weizblit N, Ellis W, Chan VW. (2005). The measurement of postoperative pain: a comparison of intensity scales in UBC Nursing Student Journal, Vol.1, Issue 1. 21younger and older surgical patients.Pain. 2005 Oct;117(3):412-20. 27. Galer BS, Jensen MP.(1997). Development and preliminary validation of a pain measure specific to  neuropathic pain: the Neuropathic Pain Scale. Neurology. Feb;48(2):332-8 28. Gagliesea L, Katz J. (2003). Age differences in postoperative pain are scale dependent: a comparison of measures of pain intensity and quality in younger and older surgical patients. Pain. 103:11\u201320. 29. Gracely, R.H. and Kwilosz, D.M. (1988). The descriptor differential scale: applying psychophysical principles to clinical pain assessment. Pain 35, pp. 279\u2013288. 30. Hall, E., Terezhalmy, D.D., &amp; Pelleu, G. (2005). A set of descriptors for the diagnosis of dental pain syndromes. Naval Dental School. 31. Herr KA, Garand L. (2001). Assessment and Measurement of  Pain in Older Adults. In Ferrell B, Ed. Pain management in  the elderly. Clinics in geriatric medicine: WB Saunders Company. 32. Herr, K., Coyne, P., Manworren, R., McCaffery, M., Pelosi, J., &amp; Wild, L. (2006). Pain Assessment in the Nonverbal Patient:  Position Statement with Clinical Practice Recommendations. The American Society for Pain Management Nursing. 33. Hjermstad MJ, Gibbins J, Haugen DF, et al. (2008). Pain assessment tools in palliative care: an urgent need for consensus. Palliat Med. 22:895-903. 34. IASP. (1994). Part III: Pain Terms, A Current List with Definitions and Notes on Usage. Classification of Chronic Pain, Second Edition. Accessed online at:http://www.iasp-pain.org/AM/Template.cfm?Section=Pain_Defi...isplay.cfm&amp;ContentID=1728 35. Jensen, M.P., Friedmen, M., Bonzo, D., &amp; Richards, P. (2006). The validity of the neuropathic pain scale for assessing diabetic  neuropathic pain in a clinical trial. Department of Rehabilitation Medicine. 36. Joyce CR, Zutshi DW, Hrubes V, Mason RM. Comparison of fixed interval and visual analogue scales for rating chronic pain. Eur J Clin Pharmacol. 1975;8:415\u2013420. 37. Jaggar, S. I. &amp; Holdcroft, A. (2005). Principles of pain evaluation. In Holdcroft, A., &amp; Jaggar, S. I. Eds. Core Topics in Pain. Cambridge: Cambridge University Press. 38. Jensen MP, Karoly P. (2003). Self-report scales and procedures for assessing pain in adults. In: Turk DC, Melzack R (Eds). Handbook of Pain Assessment. New York: Guilford Press, pp 15\u201334. 39. Jensen MP. (2003). The validity and reliability of pain measures in adults with cancer. J Pain. 4:2\u201321 40. Katz, J., &amp; Melzack, R. (1999). Measurement of pain. Surg. Clin. North Am., 79, p. 239-252. 41. Keller, S., Bann, C.M., Dodd, S.L., Schein, L., Mendoza, T.R., &amp; Cleeland, C.S. (2004). Validity of the brief pain inventory for use  in documenting the outcomes of patients with noncancer pain. American Institute for Research. 42. Keller, S., Bann, C.M., Dodd, S.L., Schein, J., Mendoza, T.R., Cleeland, C.S. (2004). Validity of the Brief Pain Inventory for use in documenting the outcomes of patients with noncancer pain. Clinical Journal of Pain, 20(5), 309-318. 43. Manias, E., Botti, M., &amp; Bucknall, T. (2002). Observation of pain assessment and management -- the complexities of clinical practice. Journal Of Clinical Nursing, 11(6), 724-733. 44. McCorkle R. (1987). The measurement of symptom distress. Seminars in Oncology Nursing. 3:248-56. 45. McLafferty, E., &amp; Farley, A. (2008). Assessing pain in patients. Nursing Standard, 22(25), 42- 46. 46. Mercadante, S. (2009). Tools for identifying cancer pain of predominantly neuropathic origin and opioid responsiveness in cancer patients. The journal of pain. 10(6), 594-601 47. Merkel, S. I., Voepel-Lewis, T., Shayevitz, J. R., &amp; Malviya, S. (1997). The FLACC: A behavioral scale for scoring postoperative pain in young children. Pediatric Nursing, 23(3), 293\u2013297. 48. Melzack R. (1975). The McGill Pain Questionnaire: Major properties and scoring methods. Pain. 1: 277-299. 49. Moro C, Brunelli C, Miccinesi G, Fallai M, Morino P, Piazza M, Labianca R, Ripamonti C. (2005).  Edmonton symptom assessment scale: Italian validation in two palliative care settings. Support Care Cancer. Jun 4. 50. Odhner M, Wegman D, Freeland N, Steinmetz A, Ingersoll G. (2003). Assessing pain control in nonverbal critically ill adults. Dimensions of Critical Care Nursing. 22:260\u2013267. 51. Portenoy, RK, Thaler HT, Kornblith AB, Lepore JM, Friedlander-Klar H, Kiyasu E, Sobel K, Coyle N, Kemeny N, Norton L. (1994). The Memorial Symptom Assessment Scale: an instrument for the evaluation of symptom prevalence, characteristics and distress. European Journal of Cancer. 30A(9):1326. 52. Queen's University School of Medicine. (2012). Palliative Care Integration Project. Accessed at: UBC Nursing Student Journal, Vol.1, Issue 1. 22http://meds.queensu.ca/palliativecare/clinical_resources_-_intro 53. Rees E, Hardy J, Ling J, Bradley K, A\u2019Hern R. (1998). The use of the Edmonton Symptom Assessment Scale (ESAS) within a palliative care unit in the UK. Palliative Medicine. 12:75-82. 54. Renee C.B. Manworren, Linda S. Hynan. (2003). Clinical Validation of FLACC: Preverbal Patient Pain Scale. Pediatric Nursing. 29(2) 55. Solman, R., Wruble, A., Rosen, G., &amp; Rom, M. (2006). Determination of clinically meaningful level of pain reduction in patients experiencing acute postoperative pain. Pain Management Nursing, 7(4), 153-158 56. Wallen GR, Wittink HM, Berger A, Carr DB. (2008). Palliative care outcome measures: translating research into practice. In: Wittink HM, Carr DB, eds. Pain Management: Evidence, Outcomes, and Quality of Life. A Sourcebook. London: Elsevier, 377\u2013 405. 57. Wang XS, Cleeland CS. (2008). Outcomes measurement in cancer pain. In: Pain Management: Evidence, Outcomes, and  Quality of Life. A Sourcebook -- Wittink HM, Carr DB, eds. London: Elsevier. 361-76. 58. Warden, V., Hurley, A.C., &amp; Volicer, L. (2003). Development and psychometric evaluation of the pain assessment in advanced dementia (PAINAD) Scale. Journal of the American Medical Directors Association, 4(1), 9-15. 59. Wong, D. and Baker, C.(1988). Pain in children: comparison of assessment scales, Pediatric Nursing, 14(1):9-17. 60. Watanabe SM, Nekolaichuk C, Beaumont C, Johnson L, Myers J, Strasser F. (2011). A multi-centre comparison of two numerical versions of the Edmonton Symptom Assessment System in palliative care patients J Pain Symptom Manage. 41:456- 468. 61. Webber, K. &amp; Davies, A.N. (2011). Validity of the memorial symptom assessment scale-short form psychological subscales in  advanced cancer patients. Royal Marsden NHS Hospital Trust 62. Weissman DE, Griffie J, Muchka S, Matson S. Building an  institutional commitment to pain management in longterm care facilities. J Pain Symptom Manage 2000; 35 20 1. In: The Australian Pain Society. (2005). Pain in Residential Aged Care  Facilities: Management Strategies. Accessed at: http://www.apsoc.org.au/owner/files/9e2c2n.pdf 63. Yadeau, J.T., Liu, S.S., Rade, M.C., Marcello, D., &amp; Liguori, G.A. (2011). Performance characteristic and validation of the  opioid-related symptom distress scalre for evaluation of analgesic side effects after orthopaedic surgery.  Department of anaesthesiology. 64. Zinke, J.L., Lam, C.S., Harden, R.N., &amp; Fogg, L. (2010). Examining the cross-cultural validity of the English short-from McGill  pain Questionnaire using the matched moderated regression methodology. Northwestern University. UBC Nursing Student Journal, Vol.1, Issue 1. 23 UBC Nursing Student Journal, Vol.1, Issue 1. 24"@en
<https://open.library.ubc.ca/cIRcle/collections/undergraduateresearch/45132/items/1.0308625>