Pain, anxiety, distress, and suffering: interrelated, but not interchangeable
2003; Elsevier BV; Volume: 142; Issue: 4 Linguagem: Inglês
10.1067/mpd.2003.194
ISSN1097-6833
AutoresCharles B. Berde, Joanne Wolfe,
Tópico(s)Family and Patient Care in Intensive Care Units
ResumoStudies published in this issue of The Journal of Pediatrics concern treatment of children in two widely different settings: children in the emergency department with acute medical conditions who receive oral midazolam to alleviate the distress of intravenous catheter placement,1McErlean M Bartfield JM Karunakar TA Whitman MCW Turley DM. Midazolam syrup as a premedication to reduce the discomfort associated with pediatric intravenous catheter insertion.J Pediatr. 2003; 142: 429-430Abstract Full Text Full Text PDF PubMed Scopus (14) Google Scholar and children with advanced cancer in the final 3 days of life who receive infusions of opioids and benzodiazepines for treatment of pain and suffering.2Dougherty M DeBaun MR. Rapid increase of morphine and benzodiazepine usage in the last three days of life in children with cancer is related to neuropathic pain.J Pediatr. 2003; 142: 373-376Abstract Full Text Full Text PDF PubMed Scopus (17) Google ScholarThe alleviation of pain and other sources of distress in childhood is a critical area of investigation from the emergency department to the home-hospice setting. Yet, little attention has been given to developing effective interventions, especially towards the end of life.3Anonymous Health Serv Res. 1998; 33: 1-3PubMed Google Scholar, 4Wolfe J Grier HE Klar N Levin SB Ellenbogen JM Salem-Schatz S et al.Symptoms and suffering at the end of life in children with cancer.N Engl J Med. 2000; 342: 326-333Crossref PubMed Scopus (901) Google Scholar We commend the authors of both studies for making the understanding of childhood experience of pain and suffering a priority. However, in both settings, although the stated aims are to treat pain, the interventions may act more directly on other symptoms, blurring distinctions between pain, anxiety, distress, and suffering (Table). These four conditions are interrelated, but it is our view that therapeutic choices can be improved by understanding the inter-relationships between these conditions, and not always by lumping them together.Table 3Definitions of termsNociceptionThe process of detection of tissue injury or inflammation by initiation and propagation of afferent neurotransmissionPain"An unpleasant sensory and emotional experience associated with actual or potential tissue damage or described in terms of such damage"42Mersky H. An investigation of pain in psychological illness. Oxford University Press, Oxford1964Google ScholarAnxietyA subjective sense of unease, dread, or forebodingDistressBecause pain and anxiety are frequentlybehaviorally indistinguishable, the combination is often referred to asdistress 12Elliott CH Jay SM Woody P. An observation scale for measuring children's distress during medical procedures.J Pediatr Psychol. 1987; 12: 543-551Crossref PubMed Scopus (153) Google Scholar, 41Kennedy RM Luhmann JD The "ouchless emergency department". Getting closer: advances in decreasing distress during painful procedures in the emergency department.Pediatr Clin North Am. 1999; 46 (vii-viii): 1215-1247Abstract Full Text Full Text PDF PubMed Scopus (76) Google ScholarSuffering"A specific state of distress that occurs when the intactness or integrity of the person is threatened or disruptedIt lasts until the threat is gone or integrity is restoredSuffering is measured in the patient's terms and is expressed in the distress they are experiencing, their assessment of the seriousness or threat of their problem and how impaired they feel themselves to be"43Cassell EJ. Diagnosing suffering: a perspective.Ann Intern Med. 1999; 131: 531-534Crossref PubMed Scopus (220) Google Scholar Open table in a new tab DeBaun et al2Dougherty M DeBaun MR. Rapid increase of morphine and benzodiazepine usage in the last three days of life in children with cancer is related to neuropathic pain.J Pediatr. 2003; 142: 373-376Abstract Full Text Full Text PDF PubMed Scopus (17) Google Scholar retrospectively reviewed patterns of opioid and benzodiazepine infusions among children with cancer at the end of life, and noted that patients whose pain appeared neuropathic in character received markedly higher infusion rates for both opioids and benzodiazepines than patients with nociceptive pain. These findings in several respects replicate our group's previous report on patterns of opioid administration at the end of life among 199 children who died of cancer over a 4-year period.5Collins JJ Grier HE Kinney HC Berde CB. Control of severe pain in children with terminal malignancy.J Pediatr. 1995; 126: 653-657Abstract Full Text Full Text PDF PubMed Scopus (130) Google Scholar Among a subgroup of 12 subjects with massive opioid dose escalation, (defined as ≥100-fold increases over an average starting dose), neuropathic pain was identified among 11 of the 12 subjects by clinical, radiographic, or neuropathologic examination.DeBaun et al2Dougherty M DeBaun MR. Rapid increase of morphine and benzodiazepine usage in the last three days of life in children with cancer is related to neuropathic pain.J Pediatr. 2003; 142: 373-376Abstract Full Text Full Text PDF PubMed Scopus (17) Google Scholar appear to prescribe both opioid and benzodiazepine infusions as a routine pattern of care. It is worth emphasizing that benzodiazepines are not analgesics, either for treatment of acute pain or chronic pain. They reduce anxiety and provide anti-emetic and sedative actions. Opioids are probably more effective than benzodiazepines in treatment of "air hunger." Benzodiazepines are probably overused for chronic anxiety. In the current climate of inadequate insurance coverage of mental health services, it is also necessary to point out that psychologic interventions for anxiety, rather than just medications, should be regarded as first-line treatment. In palliative care, anxiety can often be reduced by a regular and ongoing emphasis on communication and counseling to address fears, loneliness, anger, loss, and existential/spiritual concerns.6Block SD Billings JA. Patient requests for euthanasia and assisted suicide in terminal illness. The role of the psychiatrist.Psychosomatics. 1995; 36: 445-457Abstract Full Text PDF PubMed Scopus (83) Google ScholarConversely, opioids provide analgesia in the majority of patients in doses that preserve clarity of sensorium. Stimulants such as methylphenidate can be effective at antagonizing opioid-induced sedation and mental clouding.7Bruera E Chadwick S Brenneis C Hanson J MacDonald RN. Methylphenidate associated with narcotics for the treatment of cancer pain.Cancer Treatment Reports. 1987; 71: 67-70PubMed Google Scholar The decision to use benzodiazepine infusions to produce sedation at the end of life should, in our view, not be a routine, but should be individualized and based on explicit indications, such as the following: a situation in which very aggressive titration of opioids, adjuvants, or other approaches to pain management are either ineffective or produce intolerable side effects8Truog RD Berde CB Mitchell C Grier HE. Barbiturates in the care of the terminally ill.N Engl J Med. 1992; 327: 1678-1682Crossref PubMed Scopus (110) Google Scholar; or a situation in which a patient or their surrogate chooses sedation for relief of nonpainful suffering, such as terminal extubation.8Truog RD Berde CB Mitchell C Grier HE. Barbiturates in the care of the terminally ill.N Engl J Med. 1992; 327: 1678-1682Crossref PubMed Scopus (110) Google ScholarIn the report by DeBaun et al,2Dougherty M DeBaun MR. Rapid increase of morphine and benzodiazepine usage in the last three days of life in children with cancer is related to neuropathic pain.J Pediatr. 2003; 142: 373-376Abstract Full Text Full Text PDF PubMed Scopus (17) Google Scholar it was concerning to find apparently routine use of benzodiazepine infusions as therapy "for pain" in the subgroup with presumed neuropathic pain, with no mention of trials of a range of other analgesic options, including anticonvulsants, tricyclic antidepressants, corticosteroids, stimulants, systemic local anesthetics, very-low-dose ketamine infusions, or spinal or epidural infusions9Collins JJ Grier HE Sethna NF Wilder RT Berde CB. Regional anesthesia for pain associated with terminal pediatric malignancy.Pain. 1996; 65: 63-69Abstract Full Text PDF PubMed Scopus (62) Google Scholar of local anesthetics, opioids, or clonidine. It is plausible that some of these other therapies were tried earlier in the course of palliative care, and that in the final 3 days of life, sedative infusions were indeed appropriate, but the thought processes and therapeutic trials before a decision to use a benzodiazepine infusion are not clear. The time course of dose escalation in the weeks and months before the final 3 days is also not clarified.Should patients with advanced cancer or other illnesses be maintained in a sedated condition in the days before death?10Ventafridda V Ripamonti C De Conno F Tamburini M Cassileth BR. Symptom prevalence and control during cancer patients' last days of life.J Palliat Care. 1990; 6: 7-11PubMed Google Scholar, 11Mount B. A final crescendo of pain?.J Palliat Care. 1990; 6: 5-6PubMed Google Scholar The answer, of course, is "it depends." It depends on the nature of their physical and emotional/spiritual suffering, it depends on how successfully we can relieve their physical pain while maintaining clarity of sensorium, and most importantly, it depends on what patients or their surrogates choose. But sedation should not be instituted as a universal approach to care at the end of life.The report by McErlean et al1McErlean M Bartfield JM Karunakar TA Whitman MCW Turley DM. Midazolam syrup as a premedication to reduce the discomfort associated with pediatric intravenous catheter insertion.J Pediatr. 2003; 142: 429-430Abstract Full Text Full Text PDF PubMed Scopus (14) Google Scholar found that oral midazolam reduced observer-based measures of pain (which rate pain and anxiety or "distress,"12Elliott CH Jay SM Woody P. An observation scale for measuring children's distress during medical procedures.J Pediatr Psychol. 1987; 12: 543-551Crossref PubMed Scopus (153) Google Scholar rather than pain alone) with intravenous cannulation more effectively than placebo. Emergency department clinicians now have at least the following 4 therapeutic options: (1) oral midazolam or other sedative approaches, including nitrous oxide13Gall O Annequin D Benoit G Glabeke E Vrancea F Murat I. Adverse events of premixed nitrous oxide and oxygen for procedural sedation in children.Lancet. 2001; 358: 1514-1515Abstract Full Text Full Text PDF PubMed Scopus (104) Google Scholar, 14Annequin D Carbajal R Chauvin P Gall O Tourniare B Murat I Fixed 50% nitrous oxide oxygen mixture for painful procedures: a French survey.Pediatrics. 2000; 105: E47Crossref PubMed Scopus (176) Google Scholar, 15Luhmann JD Kennedy RM Porter FL Miller JP Jaffe DM. A randomized clinical trial of continuous-flow nitrous oxide and midazolam for sedation of young children during laceration repair.Ann Emerg Med. 2001; 37: 20-27Abstract Full Text Full Text PDF PubMed Scopus (101) Google Scholar, 16Luhmann JD Kennedy RM Jaffe DM McAllister JD. Continuous-flow delivery of nitrous oxide and oxygen: a safe and cost-effective technique for inhalation analgesia and sedation of pediatric patients.Pediatr Emerg Care. 1999; 15: 388-392Crossref PubMed Scopus (47) Google Scholar, 17Krauss B. Continuous-flow nitrous oxide: searching for the ideal procedural anxiolytic for toddlers.Ann Emerg Med. 2001; 37: 61-62Abstract Full Text Full Text PDF PubMed Scopus (30) Google Scholar; (2) topical local anesthesia18Kleiber C Sorenson M Whiteside K Gronstal BA Tannous R. Topical anesthetics for intravenous insertion in children: a randomized equivalency study.Pediatrics. 2002; 110: 758-761Crossref PubMed Scopus (98) Google Scholar, 19Halperin BA Halperin SA McGrath P Smith B Houston T Use of lidocaine-prilocaine patch to decrease intramuscular injection pain does not adversely affect the antibody response to diphtheria-tetanus-acellular pertussis-inactivated poliovirus-Haemophilus influenzae type b conjugate and hepatitis B vaccines in infants from birth to six months of age.Pediatr Infect Dis J. 2002; 21: 399-405Crossref PubMed Scopus (39) Google Scholar, 20Eichenfield LF Funk A Fallon-Friedlander S Cunningham BB A clinical study to evaluate the efficacy of ELA-Max (4% liposomal lidocaine) as compared with eutectic mixture of local anesthetics cream for pain reduction of venipuncture in children.Pediatrics. 2002; 109: 1093-1099Crossref PubMed Scopus (195) Google Scholar, 21Carceles MD Alsonso JM Garciaj-Munoz M Najera MD Castano I Vila N. Amethocaine-lidocaine cream, a new topical formulation for preventing venopuncture-induced pain in children.Reg Anesth Pain Med. 2002; 27: 289-295Crossref PubMed Google Scholar, 22Fetzer SJ. Reducing venipuncture and intravenous insertion pain with eutectic mixture of local anesthetic: a meta-analysis.Nurs Res. 2002; 51: 119-124Crossref PubMed Scopus (45) Google Scholar, 23Galinkin JL Rose JB Harris K Watcha MF. Lidocaine iontophoresis versus eutectic mixture of local anesthetics (EMLA) for IV placement in children.Anesth Analg. 2002; 94 (table of contents): 1484-1488Crossref PubMed Scopus (73) Google Scholar; (3) cognitive behavioral interventions (distraction, guided imagery, hypnosis, specifically-guided parental presence)24Jay SM Elliott CH Fitzgibbons I Woody P Siegel SE. A comparative study of cognitive behavior therapy versus general anesthesia for painful medical procedures in children.Pain. 1995; 62: 3-9Abstract Full Text PDF PubMed Scopus (97) Google Scholar, 25Jay SM Elliott CH Woody PD Siegel SE. An investigation of cognitive-behavior therapy combined with oral valium for children undergoing painful medical procedures.Health Psychol. 1991; 10: 317-322Crossref PubMed Scopus (78) Google Scholar, 26Jay SM Elliott CH Katz E Siegel SE. Cognitive-behavioral and pharmacologic interventions for childrens' distress during painful medical procedures.J Consult Clin Psychol. 1987; 55: 860-865Crossref PubMed Scopus (172) Google Scholar, 27French GM Painter EC Coury DL. Blowing away shot pain: a technique for pain management during immunization.Pediatrics. 1994; 93: 384-388PubMed Google Scholar, 28Krauss B. Managing acute pain and anxiety in children undergoing procedures in the emergency department.Emerg Med. 2001; 13: 293-304Crossref Scopus (11) Google Scholar, 29Kohen DP Olness KN Colwell SO Heimel A. The use of relaxation-mental imagery (self-hypnosis) in the management of 505 pediatric behavioral encounters.J Dev Behav Pediatr. 1984; 5: 21-25Crossref PubMed Scopus (72) Google Scholar, 30Olness K. Hypnosis in pediatric practice.Curr Probl Pediatr. 1981; 12: 1-47Abstract Full Text PDF PubMed Scopus (26) Google Scholar, 31Sugarman LI Hypnosis in a primary care practice: developing skills for the "new morbidities".J Dev Behav Pediatr. 1996; 17: 300-305Crossref PubMed Scopus (12) Google Scholar, 32Sugarman LI. Hypnosis: teaching children self-regulation.Pediatr Rev. 1996; 17: 5-11Crossref PubMed Scopus (24) Google Scholar; or (4) no adjuvant therapy.Each of these choices has associated risks, benefits, and costs. Oral midazolam is attractive because: (1) it is non-noxious to administer (unless the child struggles and refuses to drink it !); (2) it has a reversal agent, flumazenil, which can be administered either intravenously or intramuscularly; (3) it has a side-effect profile that is relatively mild; and (4) it is reasonably effective in reducing anxiety.Nevertheless, the risks associated with oral midazolam, inhaled nitrous oxide, or other sedatives, are not zero.33Pena BM Krauss B. Adverse events of procedural sedation and analgesia in a pediatric emergency department.Ann Emerg Med. 1999; 34 (4 Pt 1): 483-491Abstract Full Text PDF PubMed Scopus (235) Google Scholar, 34Cote CJ Karl HW Notterman DA Weinberg JA McCloskey C. Adverse sedation events in pediatrics: analysis of medications used for sedation.Pediatrics. 2000; 106: 633-644Crossref PubMed Scopus (431) Google Scholar In the emergency department, where patients have "full stomachs," where the consequences of injuries, infectious diseases, or other acute medical conditions may evolve over time, occasional patients may experience oversedation, hypoventilation, or aspiration pneumonitis. Several questions arise:What risk of a serious life-threatening event from oral midazolam or inhaled nitrous oxide do we accept to ameliorate the distress of IV catheter placement in this setting? 1:10,000? 1:100,000?Can we identify which children have a greater or lesser risk/benefit ratio from use of midazolam in this setting?How "slippery is the slope" from making this routine practice? Will patients and parents request midazolam for every immunization or blood test? Is that a good or bad argument against using it in the emergency department?Would more widespread use of cognitive-behavioral interventions (distraction, guided imagery, hypnosis, etc) be equally effective as midazolam in this setting for a subgroup of patients, with less risk?Several topical local anesthetic formulations reduce nociception and pain from venipuncture or intravenous catheter placement with reasonable effectiveness, particularly in elective situations in a familiar setting. They are less effective in reducing fear and "distress," and this effectiveness may vary according to age, temperament, previous experiences with needle procedures, and other factors. Topical local anesthetics have some risks and costs, though overall the risks are quite low.A variety of cognitive-behavioral interventions are effective for reducing the distress from pediatric needle procedures. In our view, they should be used more widely, and should be taught as an integral part of the training of physicians, nurses, and other clinicians.31Sugarman LI Hypnosis in a primary care practice: developing skills for the "new morbidities".J Dev Behav Pediatr. 1996; 17: 300-305Crossref PubMed Scopus (12) Google ScholarIn studies of effectiveness of sedation, our view is that outcome measures should not be limited solely to observational distress measures at the immediate time of the procedure. For example, oral midazolam administered before mask induction of general anesthesia favorably influenced a variety of behavioral indices during the weeks after surgery.35Kain ZN Mayes LC Wang SM Caramico LA Krivutza DM Hofstadter MB. Parental presence and a sedative premedicant for children undergoing surgery: a hierarchical study.Anesthesiology. 2000; 92: 939-946Crossref PubMed Scopus (191) Google Scholar, 36Kain ZN Wang SM Mayes LC Caramico LA Hofstadter MB. Distress during the induction of anesthesia and postoperative behavioral outcomes.Anesth Analg. 1999; 88: 1042-1047Crossref PubMed Google Scholar, 37Kain ZN Mayes LC Wang SM Hofstadter MB. Postoperative behavioral outcomes in children: effects of sedative premedication.Anesthesiology. 1999; 90: 758-765Crossref PubMed Scopus (179) Google Scholar, 38Kain ZN Mayes LC Caldwell-Andrews AA Alexander GM Krivutza DM Teague BA et al.Sleeping characteristics of children undergoing outpatient elective surgery.Anesthesiology. 2002; 97: 1093-1101Crossref PubMed Scopus (58) Google ScholarWe are not suggesting a return to the days of "brutane," and we enthusiastically support widespread use of analgesia and sedation for a wide range of emergency department procedures, ranging from laceration repair to fracture reduction to lumbar puncture. Unrelieved pain produces harm as well.39Weisman SJ Bernstein B Schecter NL. Consequences of inadequate analgesia during painful procedures in children.Arch Pediatr Adolesc Med. 1998; 152: 147-149Crossref PubMed Scopus (344) Google Scholar Several of our colleagues have named their hospital-wide approaches to alleviation of pain and distress by names such as "ouchless zones"40Schechter NL Blankson V Pachter LM Sullivan CM Costa L. The ouchless place: no pain, children's gain.Pediatrics. 1997; 99: 890-894Crossref PubMed Scopus (64) Google Scholar, 41Kennedy RM Luhmann JD The "ouchless emergency department". Getting closer: advances in decreasing distress during painful procedures in the emergency department.Pediatr Clin North Am. 1999; 46 (vii-viii): 1215-1247Abstract Full Text Full Text PDF PubMed Scopus (76) Google Scholar or "pain-free pediatrics." Although we support systematic approaches to improving pain treatment for children, there is a sense in which such names can promote unrealistic expectations. Neither the world at large nor the hospital can realistically be a "pain-free" or "ouchless" place. With the best use of current and future pharmacotherapy, there will still be a role for helping patients cope with pain, distress, anxiety and suffering. Routine needle procedures, including venipuncture and immunization, may be viewed by many as necessary parts of life, which can be made less noxious, but not totally "ouchless" by topical analgesics, along with better use of cognitive-behavioral approaches, including distraction, hypnosis, appropriate explanation, and support of positive coping strategies.The alleviation of pain, anxiety, suffering, and distress in children, no matter what the setting, is a high priority. The articles by McErlean et al1McErlean M Bartfield JM Karunakar TA Whitman MCW Turley DM. Midazolam syrup as a premedication to reduce the discomfort associated with pediatric intravenous catheter insertion.J Pediatr. 2003; 142: 429-430Abstract Full Text Full Text PDF PubMed Scopus (14) Google Scholar and Debaun et al2Dougherty M DeBaun MR. Rapid increase of morphine and benzodiazepine usage in the last three days of life in children with cancer is related to neuropathic pain.J Pediatr. 2003; 142: 373-376Abstract Full Text Full Text PDF PubMed Scopus (17) Google Scholar begin to elucidate approaches to the management of these inter-related symptoms in children in two very different settings. However, the strategies presented here should be considered with caution, considering the consequences of using medications alone in striving to enhance comfort in children. Whether the experience of distress is limited to an emergency department visit, or is as critical as the final days of a child's life, whenever possible, strategies that preserve a child's ability to clearly interact with others and the environment should be fully considered. Studies published in this issue of The Journal of Pediatrics concern treatment of children in two widely different settings: children in the emergency department with acute medical conditions who receive oral midazolam to alleviate the distress of intravenous catheter placement,1McErlean M Bartfield JM Karunakar TA Whitman MCW Turley DM. Midazolam syrup as a premedication to reduce the discomfort associated with pediatric intravenous catheter insertion.J Pediatr. 2003; 142: 429-430Abstract Full Text Full Text PDF PubMed Scopus (14) Google Scholar and children with advanced cancer in the final 3 days of life who receive infusions of opioids and benzodiazepines for treatment of pain and suffering.2Dougherty M DeBaun MR. Rapid increase of morphine and benzodiazepine usage in the last three days of life in children with cancer is related to neuropathic pain.J Pediatr. 2003; 142: 373-376Abstract Full Text Full Text PDF PubMed Scopus (17) Google Scholar The alleviation of pain and other sources of distress in childhood is a critical area of investigation from the emergency department to the home-hospice setting. Yet, little attention has been given to developing effective interventions, especially towards the end of life.3Anonymous Health Serv Res. 1998; 33: 1-3PubMed Google Scholar, 4Wolfe J Grier HE Klar N Levin SB Ellenbogen JM Salem-Schatz S et al.Symptoms and suffering at the end of life in children with cancer.N Engl J Med. 2000; 342: 326-333Crossref PubMed Scopus (901) Google Scholar We commend the authors of both studies for making the understanding of childhood experience of pain and suffering a priority. However, in both settings, although the stated aims are to treat pain, the interventions may act more directly on other symptoms, blurring distinctions between pain, anxiety, distress, and suffering (Table). These four conditions are interrelated, but it is our view that therapeutic choices can be improved by understanding the inter-relationships between these conditions, and not always by lumping them together. DeBaun et al2Dougherty M DeBaun MR. Rapid increase of morphine and benzodiazepine usage in the last three days of life in children with cancer is related to neuropathic pain.J Pediatr. 2003; 142: 373-376Abstract Full Text Full Text PDF PubMed Scopus (17) Google Scholar retrospectively reviewed patterns of opioid and benzodiazepine infusions among children with cancer at the end of life, and noted that patients whose pain appeared neuropathic in character received markedly higher infusion rates for both opioids and benzodiazepines than patients with nociceptive pain. These findings in several respects replicate our group's previous report on patterns of opioid administration at the end of life among 199 children who died of cancer over a 4-year period.5Collins JJ Grier HE Kinney HC Berde CB. Control of severe pain in children with terminal malignancy.J Pediatr. 1995; 126: 653-657Abstract Full Text Full Text PDF PubMed Scopus (130) Google Scholar Among a subgroup of 12 subjects with massive opioid dose escalation, (defined as ≥100-fold increases over an average starting dose), neuropathic pain was identified among 11 of the 12 subjects by clinical, radiographic, or neuropathologic examination. DeBaun et al2Dougherty M DeBaun MR. Rapid increase of morphine and benzodiazepine usage in the last three days of life in children with cancer is related to neuropathic pain.J Pediatr. 2003; 142: 373-376Abstract Full Text Full Text PDF PubMed Scopus (17) Google Scholar appear to prescribe both opioid and benzodiazepine infusions as a routine pattern of care. It is worth emphasizing that benzodiazepines are not analgesics, either for treatment of acute pain or chronic pain. They reduce anxiety and provide anti-emetic and sedative actions. Opioids are probably more effective than benzodiazepines in treatment of "air hunger." Benzodiazepines are probably overused for chronic anxiety. In the current climate of inadequate insurance coverage of mental health services, it is also necessary to point out that psychologic interventions for anxiety, rather than just medications, should be regarded as first-line treatment. In palliative care, anxiety can often be reduced by a regular and ongoing emphasis on communication and counseling to address fears, loneliness, anger, loss, and existential/spiritual concerns.6Block SD Billings JA. Patient requests for euthanasia and assisted suicide in terminal illness. The role of the psychiatrist.Psychosomatics. 1995; 36: 445-457Abstract Full Text PDF PubMed Scopus (83) Google Scholar Conversely, opioids provide analgesia in the majority of patients in doses that preserve clarity of sensorium. Stimulants such as methylphenidate can be effective at antagonizing opioid-induced sedation and mental clouding.7Bruera E Chadwick S Brenneis C Hanson J MacDonald RN. Methylphenidate associated with narcotics for the treatment of cancer pain.Cancer Treatment Reports. 1987; 71: 67-70PubMed Google Scholar The decision to use benzodiazepine infusions to produce sedation at the end of life should, in our view, not be a routine, but should be individualized and based on explicit indications, such as the following: a situation in which very aggressive titration of opioids, adjuvants, or other approaches to pain management are either ineffective or produce intolerable side effects8Truog RD Berde CB Mitchell C Grier HE. Barbiturates in the care of the terminally ill.N Engl J Med. 1992; 327: 1678-1682Crossref PubMed Scopus (110) Google Scholar; or a situation in which a patient or their surrogate chooses sedation for relief of nonpainful suffering, such as terminal extubation.8Truog RD Berde CB Mitchell C Grier HE. Barbiturates in the care of the terminally ill.N Engl J Med. 1992; 327: 1678-1682Crossref PubMed Scopus (110) Google Scholar In the report by DeBaun et al,2Dougherty M DeBaun MR. Rapid increase of morphine and benzodiazepine usage in the last three days of life in children with cancer is related to neuropathic pain.J Pediatr. 2003; 142: 373-376Abstract Full Text Full Text PDF PubMed Scopus (17) Google Scholar it was concerning to find apparently routine use of benzodiazepine infusions as therapy "for pain" in the subgroup with presumed neuropathic pain, with no mention of trials of a range of other analgesic options, including anticonvulsants, tricyclic antidepressants, corticosteroids, stimulants, systemic local anesthetics, very-low-dose ketamine infusions, or spinal or epidural infusions9Collins JJ Grier HE Sethna NF Wilder RT Berde CB. Regional anesthesia for pain associated with terminal pediatric malignancy.Pain. 1996; 65: 63-69Abstract Full Text PDF PubMed Scopus (62) Google Scholar of local anesthetics, opioids, or clonidine. It is plausible that some of these other therapies were tried earlier in the course of palliative care, and that in the final 3 days of life, sedative infusions were indeed appropriate, but the thought processes and therapeutic trials before a decision to use a benzodiazepine infusion are not clear. The time course of dose escalation in the weeks and months before the final 3 days is also not clarified. Should patients with advanced cancer or other illnesses be maintained in a sedated condition in the days before death?10Ventafridda V Ripamonti C De Conno F Tamburini M Cassileth BR. Symptom prevalence and control during cancer patients' last days of life.J Palliat Care. 1990; 6: 7-11PubMed Google Scholar, 11Mount B. A final crescendo of pain?.J Palliat Care. 1990; 6: 5-6PubMed Google Scholar The answer, of course, is "it depends." It depends on the nature of their physical and emotional/spiritual suffering, it depends on how successfully we can relieve their physical pain while maintaining clarity of sensorium, and most importantly, it depends on what patients or their surrogates choose. But sedation should not be instituted as a universal approach to care at the end of life. The report by McErlean et al1McErlean M Bartfield JM Karunakar TA Whitman MCW Turley DM. Midazolam syrup as a premedication to reduce the discomfort associated with pediatric intravenous catheter insertion.J Pediatr. 2003; 142: 429-430Abstract Full Text Full Text PDF PubMed Scopus (14) Google Scholar found that oral midazolam reduced observer-based measures of pain (which rate pain and anxiety or "distress,"12Elliott CH Jay SM Woody P. An observation scale for measuring children's distress during medical procedures.J Pediatr Psychol. 1987; 12: 543-551Crossref PubMed Scopus (153) Google Scholar rather than pain alone) with intravenous cannulation more effectively than placebo. Emergency department clinicians now have at least the following 4 therapeutic options: (1) oral midazolam or other sedative approaches, including nitrous oxide13Gall O Annequin D Benoit G Glabeke E Vrancea F Murat I. Adverse events of premixed nitrous oxide and oxygen for procedural sedation in children.Lancet. 2001; 358: 1514-1515Abstract Full Text Full Text PDF PubMed Scopus (104) Google Scholar, 14Annequin D Carbajal R Chauvin P Gall O Tourniare B Murat I Fixed 50% nitrous oxide oxygen mixture for painful procedures: a French survey.Pediatrics. 2000; 105: E47Crossref PubMed Scopus (176) Google Scholar, 15Luhmann JD Kennedy RM Porter FL Miller JP Jaffe DM. A randomized clinical trial of continuous-flow nitrous oxide and midazolam for sedation of young children during laceration repair.Ann Emerg Med. 2001; 37: 20-27Abstract Full Text Full Text PDF PubMed Scopus (101) Google Scholar, 16Luhmann JD Kennedy RM Jaffe DM McAllister JD. Continuous-flow delivery of nitrous oxide and oxygen: a safe and cost-effective technique for inhalation analgesia and sedation of pediatric patients.Pediatr Emerg Care. 1999; 15: 388-392Crossref PubMed Scopus (47) Google Scholar, 17Krauss B. Continuous-flow nitrous oxide: searching for the ideal procedural anxiolytic for toddlers.Ann Emerg Med. 2001; 37: 61-62Abstract Full Text Full Text PDF PubMed Scopus (30) Google Scholar; (2) topical local anesthesia18Kleiber C Sorenson M Whiteside K Gronstal BA Tannous R. Topical anesthetics for intravenous insertion in children: a randomized equivalency study.Pediatrics. 2002; 110: 758-761Crossref PubMed Scopus (98) Google Scholar, 19Halperin BA Halperin SA McGrath P Smith B Houston T Use of lidocaine-prilocaine patch to decrease intramuscular injection pain does not adversely affect the antibody response to diphtheria-tetanus-acellular pertussis-inactivated poliovirus-Haemophilus influenzae type b conjugate and hepatitis B vaccines in infants from birth to six months of age.Pediatr Infect Dis J. 2002; 21: 399-405Crossref PubMed Scopus (39) Google Scholar, 20Eichenfield LF Funk A Fallon-Friedlander S Cunningham BB A clinical study to evaluate the efficacy of ELA-Max (4% liposomal lidocaine) as compared with eutectic mixture of local anesthetics cream for pain reduction of venipuncture in children.Pediatrics. 2002; 109: 1093-1099Crossref PubMed Scopus (195) Google Scholar, 21Carceles MD Alsonso JM Garciaj-Munoz M Najera MD Castano I Vila N. Amethocaine-lidocaine cream, a new topical formulation for preventing venopuncture-induced pain in children.Reg Anesth Pain Med. 2002; 27: 289-295Crossref PubMed Google Scholar, 22Fetzer SJ. Reducing venipuncture and intravenous insertion pain with eutectic mixture of local anesthetic: a meta-analysis.Nurs Res. 2002; 51: 119-124Crossref PubMed Scopus (45) Google Scholar, 23Galinkin JL Rose JB Harris K Watcha MF. Lidocaine iontophoresis versus eutectic mixture of local anesthetics (EMLA) for IV placement in children.Anesth Analg. 2002; 94 (table of contents): 1484-1488Crossref PubMed Scopus (73) Google Scholar; (3) cognitive behavioral interventions (distraction, guided imagery, hypnosis, specifically-guided parental presence)24Jay SM Elliott CH Fitzgibbons I Woody P Siegel SE. 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Oral midazolam is attractive because: (1) it is non-noxious to administer (unless the child struggles and refuses to drink it !); (2) it has a reversal agent, flumazenil, which can be administered either intravenously or intramuscularly; (3) it has a side-effect profile that is relatively mild; and (4) it is reasonably effective in reducing anxiety. Nevertheless, the risks associated with oral midazolam, inhaled nitrous oxide, or other sedatives, are not zero.33Pena BM Krauss B. Adverse events of procedural sedation and analgesia in a pediatric emergency department.Ann Emerg Med. 1999; 34 (4 Pt 1): 483-491Abstract Full Text PDF PubMed Scopus (235) Google Scholar, 34Cote CJ Karl HW Notterman DA Weinberg JA McCloskey C. Adverse sedation events in pediatrics: analysis of medications used for sedation.Pediatrics. 2000; 106: 633-644Crossref PubMed Scopus (431) Google Scholar In the emergency department, where patients have "full stomachs," where the consequences of injuries, infectious diseases, or other acute medical conditions may evolve over time, occasional patients may experience oversedation, hypoventilation, or aspiration pneumonitis. Several questions arise: What risk of a serious life-threatening event from oral midazolam or inhaled nitrous oxide do we accept to ameliorate the distress of IV catheter placement in this setting? 1:10,000? 1:100,000?Can we identify which children have a greater or lesser risk/benefit ratio from use of midazolam in this setting?How "slippery is the slope" from making this routine practice? Will patients and parents request midazolam for every immunization or blood test? Is that a good or bad argument against using it in the emergency department?Would more widespread use of cognitive-behavioral interventions (distraction, guided imagery, hypnosis, etc) be equally effective as midazolam in this setting for a subgroup of patients, with less risk? Several topical local anesthetic formulations reduce nociception and pain from venipuncture or intravenous catheter placement with reasonable effectiveness, particularly in elective situations in a familiar setting. They are less effective in reducing fear and "distress," and this effectiveness may vary according to age, temperament, previous experiences with needle procedures, and other factors. Topical local anesthetics have some risks and costs, though overall the risks are quite low. A variety of cognitive-behavioral interventions are effective for reducing the distress from pediatric needle procedures. In our view, they should be used more widely, and should be taught as an integral part of the training of physicians, nurses, and other clinicians.31Sugarman LI Hypnosis in a primary care practice: developing skills for the "new morbidities".J Dev Behav Pediatr. 1996; 17: 300-305Crossref PubMed Scopus (12) Google Scholar In studies of effectiveness of sedation, our view is that outcome measures should not be limited solely to observational distress measures at the immediate time of the procedure. For example, oral midazolam administered before mask induction of general anesthesia favorably influenced a variety of behavioral indices during the weeks after surgery.35Kain ZN Mayes LC Wang SM Caramico LA Krivutza DM Hofstadter MB. Parental presence and a sedative premedicant for children undergoing surgery: a hierarchical study.Anesthesiology. 2000; 92: 939-946Crossref PubMed Scopus (191) Google Scholar, 36Kain ZN Wang SM Mayes LC Caramico LA Hofstadter MB. Distress during the induction of anesthesia and postoperative behavioral outcomes.Anesth Analg. 1999; 88: 1042-1047Crossref PubMed Google Scholar, 37Kain ZN Mayes LC Wang SM Hofstadter MB. Postoperative behavioral outcomes in children: effects of sedative premedication.Anesthesiology. 1999; 90: 758-765Crossref PubMed Scopus (179) Google Scholar, 38Kain ZN Mayes LC Caldwell-Andrews AA Alexander GM Krivutza DM Teague BA et al.Sleeping characteristics of children undergoing outpatient elective surgery.Anesthesiology. 2002; 97: 1093-1101Crossref PubMed Scopus (58) Google Scholar We are not suggesting a return to the days of "brutane," and we enthusiastically support widespread use of analgesia and sedation for a wide range of emergency department procedures, ranging from laceration repair to fracture reduction to lumbar puncture. Unrelieved pain produces harm as well.39Weisman SJ Bernstein B Schecter NL. Consequences of inadequate analgesia during painful procedures in children.Arch Pediatr Adolesc Med. 1998; 152: 147-149Crossref PubMed Scopus (344) Google Scholar Several of our colleagues have named their hospital-wide approaches to alleviation of pain and distress by names such as "ouchless zones"40Schechter NL Blankson V Pachter LM Sullivan CM Costa L. The ouchless place: no pain, children's gain.Pediatrics. 1997; 99: 890-894Crossref PubMed Scopus (64) Google Scholar, 41Kennedy RM Luhmann JD The "ouchless emergency department". Getting closer: advances in decreasing distress during painful procedures in the emergency department.Pediatr Clin North Am. 1999; 46 (vii-viii): 1215-1247Abstract Full Text Full Text PDF PubMed Scopus (76) Google Scholar or "pain-free pediatrics." Although we support systematic approaches to improving pain treatment for children, there is a sense in which such names can promote unrealistic expectations. Neither the world at large nor the hospital can realistically be a "pain-free" or "ouchless" place. With the best use of current and future pharmacotherapy, there will still be a role for helping patients cope with pain, distress, anxiety and suffering. Routine needle procedures, including venipuncture and immunization, may be viewed by many as necessary parts of life, which can be made less noxious, but not totally "ouchless" by topical analgesics, along with better use of cognitive-behavioral approaches, including distraction, hypnosis, appropriate explanation, and support of positive coping strategies. The alleviation of pain, anxiety, suffering, and distress in children, no matter what the setting, is a high priority. The articles by McErlean et al1McErlean M Bartfield JM Karunakar TA Whitman MCW Turley DM. Midazolam syrup as a premedication to reduce the discomfort associated with pediatric intravenous catheter insertion.J Pediatr. 2003; 142: 429-430Abstract Full Text Full Text PDF PubMed Scopus (14) Google Scholar and Debaun et al2Dougherty M DeBaun MR. Rapid increase of morphine and benzodiazepine usage in the last three days of life in children with cancer is related to neuropathic pain.J Pediatr. 2003; 142: 373-376Abstract Full Text Full Text PDF PubMed Scopus (17) Google Scholar begin to elucidate approaches to the management of these inter-related symptoms in children in two very different settings. However, the strategies presented here should be considered with caution, considering the consequences of using medications alone in striving to enhance comfort in children. Whether the experience of distress is limited to an emergency department visit, or is as critical as the final days of a child's life, whenever possible, strategies that preserve a child's ability to clearly interact with others and the environment should be fully considered. Drs Baruch Krauss and Larry Sugarman provided helpful discussions.
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