Improving Care for the End of Life, Online Edition The Palliative Care Policy Center

Sourcebook : Improving Care for the End of Life : 3.9 Use Clinical Practice Guidelines

Hundreds of expert panels, individuals, and organizations have developed guidelines on everything from managing urinary incontinence to treating HIV/AIDS patients. Guidelines, sometimes called clinical pathways, are available; these highlight best practices in treating the array of problems patients face at the end of life. The federal government has launched a new Web site,, from which one can download carefully selected guidelines. In addition to guidelines developed by federal agencies, professional organizations (e.g., the American Pain Society) and international groups (e.g., the World Health Organization) have developed their own. The Joint Commission on Accreditation of Healthcare Organizations (JCAHO) is revising its standards to incorporate pain assessment and treatment. These materials - and others developed by regional and local organizations - point the way to improved pain management.

Improvement teams may want to try various guidelines. In selecting one, keep in mind these common attributes of good guidelines:

Is there evidence that guidelines work or improve patient care? Researchers in Washington State recently reported that the use of guidelines improved "usual pain outcomes." The accompanying sidebar describes results of a study using clinical practice guidelines to improve management of cancer pain.

Using an Algorithm

In a study of 81 cancer patients, researchers at Washington State’s Swedish Medical Center found that the use of a treatment algorithm for pain management, based on guidelines from AHCPR, improved “usual pain” outcomes. The study’s Cancer Pain Algorithm addresses pain assessment, analgesic drug choice decisions, and reassessment. The decision tree includes side effect treatment protocols, equianalgesic conversion charts, and a primer for intractable pain.

Researchers followed patients for three months, taking pain measurements at five intervals: at baseline and at two weeks; and one, two, and three months after the start of the intervention. Pain outcomes were “usual” and “worst” pain as measured by a Brief Pain Inventory. Pain outcome tools included:

  • An average pain intensity score from a Daily Pain Diary
  • Pain ‘character’ using descriptive words and a ranking scale
  • Pain interference with seven different activities
  • Pain location
  • A composite score based on intensity, character, relief, location, and interference

Patients whose care was facilitated by use of the pain algorithm had statistically superior results in reduction of “usual pain." Control group patients had an initial decrease in pain intensity, but finished the study with a slight increase in usual pain scores. Patients in the algorithm group, however, experienced a steady decrease in usual pain scores. (Du Pen, et al., 1999)

Worst Pain Scores: Algorithm vs. Standard Care., DuPen et al., 1999 Usual Pain Score: Algorithm vs. Standard Care, DuPen, et al., 1999.

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This online version of the book Improving Care for the End of Life: A Sourcebook for Health Care Managers and Clinicians is provided with permission of Americans for Better Care of the Dying [ ] and Oxford University Press. All rights reserved.

For further information on quality improvement in end-of-life care visit The Palliative Care Policy Center [ ].

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