Valoración de los síntomas del paciente crítico
¿Quien lo interpreta mejor?: A menudo minusvalorados, su evaluación no es fácil, especialmente en los pacientes con dificultades para comunicarse. Por ese motivo es importante saber en qué medida somos capaces de interpretar unos y otros la importancia de los síntomas del paciente.
Autor(es): Puntillo KA, Neuhaus J, Arai S, Paul SM, Gropper MA, Cohen NH, Miaskowski
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La atención a los síntomas experimentados por los pacientes críticos (por su propia naturaleza subjetivos) es fundamental desde una perspectiva de una asistencia centrada en el paciente.1,2 A menudo minusvalorados, su evaluación no es fácil, especialmente en los pacientes con dificultades para comunicarse. Por ese motivo es importante saber en qué medida somos capaces de interpretar unos y otros la importancia de los síntomas del paciente
Se llevó a cabo un estudio en dos UCI de un hospital de EEUU para determinar el grado de correlación en la valoración de la intensidad y el impacto emocional de un listado de diez síntomas entre pacientes, familiares, médicos y enfermeras. Dicho listado incluía: dolor, cansancio, disnea, intranquilidad, ansiedad, tristeza, hambre, miedo, sed y confusión. La intensidad y el impacto de dichos síntomas se puntuaba por separado, de 1 a 3 (leve, moderado o grave). Se incluyeron en el estudio 254 pacientes, 243 familiares, 103 enfermeras y 92 médicos. El coeficiente de correlación en la valoración de la intensidad de los síntomas fue alto para seis de los diez síntomas entre pacientes y familiares, para ninguno de ellos entre pacientes y enfermeras y para tres entre pacientes y médicos. Del mismo modo, para la valoración del impacto emocional de los síntomas la correlación fue mayor en el caso de los familiares que en el de médicos y enfermeras. Médicos y enfermeras tendieron a sobrevalorar los síntomas más que los familiares.
El estudio demuestra, con datos empíricos, que la valoración que son capaces de realizar los familiares de los síntomas de los pacientes críticos suele ser más válida que la de los profesionales, lo que tiene importantes implicaciones acerca del papel que puede jugar la familia en los cuidados del paciente crítico. La mayoría de los familiares que participaron en el estudio eran esposos y con mucho tiempo previo de convivencia, lo que explica su capacidad para interpretar los síntomas más adecuadamente que los profesionales. Su papel puede ser importante no solo en la valoración de los síntomas, sino también en su manejo.3
►Artículo ➔ Noticia ➲ Tema básico ➜ Editorial
1. Chanques G, Sebbane M, Barbotte E, et al. A prospective study of pain at rest: Incidence and characteristics of an unrecognized symptom in surgical and trauma versus medical intensive care unit patients.Anesthesiology. 2007;107:858–860. [PubMed]
2. Stanik-Hutt JA, Soeken KL, Belcher AE, et al. Pain experiences of traumatically injured patients in a critical care setting. Am J Crit Care. 2001;10:252–259. [PubMed]
3. Puntillo KA, White C, Morris AB, et al. Patients’ perceptions and responses to procedural pain: Results from Thunder Project II. Am J Crit Care. 2001;10:238–251. [PubMed]
4. Arroyo-Novoa CM, Figueroa-Ramos MI, Puntillo KA, et al. Pain related to tracheal suctioning in awake acutely and critically ill adults: A descriptive study. Intensive Crit Care Nurs. 2008;24:20–27. [PubMed]
5. Stotts NA, Puntillo K, Bonham Morris A, et al. Wound care pain in hospitalized adult patients. Heart Lung. 2004;33:321–332. [PubMed]
6. Powers J, Bennett SJ. Measurement of dyspnea in patients treated with mechanical ventilation. Am J Crit Care. 1999;8:254–261. [PubMed]
7. Knebel AR, Janson-Bjerklie SL, Malley JD, et al. Comparison of breathing comfort during weaning with two ventilatory modes. Am J Respir Crit Care Med. 1994;149:14–18. [PubMed]
8. Hallenberg B, Bergbom-Engberg I, Haljamäe H. Patients’ experiences of postoperative respirator treatment–influence of anaesthetic and pain treatment regimens. Acta Anaesthesiol Scand. 1990;34:557–562.[PubMed]
9. Riggio RE, Singer RD, Hartman K, et al. Psychological issues in the care of critically-ill respirator patients: Differential perceptions of patients, relatives, and staff. Psychol Rep. 1982;51:363–369. [PubMed]
10. Wilson VS. Identification of stressors related to patients’ psychologic responses to the surgical intensive care unit. Heart Lung. 1987;16:267–273. [PubMed]
11. Cochran J, Ganong LH. A comparison of nurses’ and patients’ perceptions of intensive care unit stressors. J Adv Nurs. 1989;14:1038–1043. [PubMed]
12. Ely EW, Inouye SK, Bernard GR, et al. Delirium in mechanically ventilated patients: Validity and reliability of the confusion assessment method for the intensive care unit (CAM-ICU) JAMA.2001;286:2703–2710. [PubMed]
13. Novaes MA, Knobel E, Bark AM, et al. Stressors in ICU: Perception of the patient, relatives and health care team. Intensive Care Med. 1999;25:1421–1426. [PubMed]
14. Desbiens NA, Mueller-Rizner N, Connors AF, Jr, et al. The symptom burden of seriously ill hospitalized patients. SUPPORT Investigators. Study to Understand Prognoses and Preferences for Outcome and Risks of Treatment. J Pain Symptom Manage. 1999;17:248–255. [PubMed]
15. Nelson JE, Meier DE, Oei EJ, et al. Self-reported symptom experience of critically ill cancer patients receiving intensive care. Crit Care Med. 2001;29:277–282. [PubMed]
16. Puntillo K, Pasero C, Li D, et al. Evaluation of pain in ICU patients. Chest. 2009;135:1069–1074.[PubMed]
17. Hickman SE, Tilden VP, Tolle SW. Family reports of dying patients’ distress: The adaptation of a research tool to assess global symptom distress in the last week of life. J Pain Symptom Manage.2001;22:565–574.[PubMed]
18. Nekolaichuk CL, Bruera E, Spachynski K, et al. A comparison of patient and proxy symptom assessments in advanced cancer patients. Palliat Med. 1999;13:311–323. [PubMed]
19. Sneeuw KC, Aaronson NK, Sprangers MA, et al. Evaluating the quality of life of cancer patients: Assessments by patients, significant others, physicians and nurses. Br J Cancer. 1999;81:87–94.[PMC free article] [PubMed]
20. Lobchuk MM, Kristjanson L, Degner L, et al. Perceptions of symptom distress in lung cancer patients: I. Congruence between patients and primary family caregivers. J Pain Symptom Manage. 1997;14:136–146.[PubMed]
21. Teno JM, Coppola KM. For every numerator, you need a denominator: A simple statement but key to measuring the quality of care of the “dying” J_Pain Symptom Manage. 1999;17:109–113. [PubMed]
22. Strömgren AS, Groenvold M, Sorensen A, et al. Symptom recognition in advanced cancer. A comparison of nursing records against patient self-rating. Acta Anaesthesiol Scand. 2001;45:1080–1085.[PubMed]
23. Strömgren AS, Groenvold M, Pedersen L, et al. Does the medical record cover the symptoms experienced by cancer patients receiving palliative care? A comparison of the record and patient self-rating. J Pain Symptom Manage. 2001;21:189–196. [PubMed]
24. Sneeuw KC, Aaronson NK, Osoba D, et al. The use of significant others as proxy raters of the quality of life of patients with brain cancer. Med Care. 1997;35:490–506. [PubMed]
25. Nekolaichuk CL, Maguire TO, Suarez-Almazor M, et al. Assessing the reliability of patient, nurse, and family caregiver symptom ratings in hospitalized advanced cancer patients. J Clin Oncol. 1999;17:3621–3630.[PubMed]
26. Puntillo KA, Miaskowski C, Kehrle K, et al. Relationship between behavioral and physiological indicators of pain, critical care patients’ self-reports of pain, and opioid administration. Crit Care Med.1997;25:1159–1166.[PubMed]
27. Desbiens NA, Mueller-Rizner N. How well do surrogates assess the pain of seriously ill patients? Crit Care Med. 2000;28:1347–1352. [PubMed]
28. Price DD, Harkins SW, Baker C. Sensory-affective relationships among different types of clinical and experimental pain. Pain. 1987;28:297–307. [PubMed]
29. Broberger E, Tishelman C, von Essen L. Discrepancies and similarities in how patients with lung cancer and their professional and family caregivers assess symptom occurrence and symptom distress. J Pain Symptom Manage. 2005;29:572–583. [PubMed]
30. Knaus WA, Draper EA, Wagner DP, et al. APACHE II: A severity of disease classification system. Crit Care Med. 1985;13:818–829. [PubMed]
31. Knaus WA, Harrell FE, Jr, Lynn J, et al. The SUPPORT prognostic model. Objective estimates of survival for seriously ill hospitalized adults. Study to understand prognoses and preferences for outcomes and risks of treatments. Ann Intern Med. 1995;122:191–203. [PubMed]
32. The SUPPORT Principal Investigators: A controlled trial to improve care for seriously ill hospitalized patients. The study to understand prognoses and preferences for outcomes and risks of treatments (SUPPORT) JAMA. 1995;274:1591–1598. [PubMed]
33. Puntillo KA, Arai S, Cohen NH, et al. Symptoms experienced by intensive care unit patients at high risk of dying. Crit Care Med. 2010;38:2155–2160. [PMC free article] [PubMed]
34. Damiano AM, Bergner M, Draper EA, et al. Reliability of a measure of severity of illness: Acute physiology of chronic health evaluation–II. J Clin Epidemiol. 1992;45:93–101. [PubMed]
35. Devlin JW, Boleski G, Mlynarek M, et al. Motor Activity Assessment Scale: A valid and reliable sedation scale for use with mechanically ventilated patients in an adult surgical intensive care unit. Crit Care Med. 1999;27:1271–1275. [PubMed]
36. Fleiss JL, Levin B, Paik MC. Statistical Methods for Rates and Proportions. New York: John Wiley and Sons; 2003. pp. 218–226.
37. Liang KY, Zeger SL. Longitudinal data analysis using generalized linear models. Biometrika.1986;73:13–22.
38. Hanley JA, Negassa A, Edwardes MD, et al. Statistical analysis of correlated data using generalized estimating equations: An orientation. Am J Epidemiol. 2003;157:364–375. [PubMed]
39. Hemphill JF. Interpreting the magnitudes of correlation coefficients. Am Psychol. 2003;58:78–79.[PubMed]
40. Hox J. Multilevel Analysis: Techniques and Applications. 2. New York: Routledge; 2010. p. 244.
41. Skrondal A, Rabe-Hesketh S. Generalized Latent Variable Modeling: Multilevel, Longitudinal, and Structural Equation Models. Boca Raton, FL: Chapman and Hall/CRC; 2004. pp. 321–348.
42. Hinton J. How reliable are relatives’ retrospective reports of terminal illness? Patients and relatives’ accounts compared. Soc Sci Med. 1996;43:1229–1236. [PubMed]
43. Puntillo KA, Smith D, Arai S, et al. Critical care nurses provide their perspectives of patients’ symptoms in intensive care units. Heart Lung. 2008;37:466–475. [PubMed]
44. Lobchuk MM, Kristjanson L, Degner L, et al. Perception of symptom distress in lung cancer patients: Agreement between patients and their caregiving relatives. Pflege. 1999;12:352–361. [PubMed]
45. Miaskowski C, Zimmer EF, Barrett KM, et al. Differences in patients’ and family caregivers’ perceptions of the pain experience influence patient and caregiver outcomes. Pain. 1997;72:217–226. [PubMed]
46. Ferrell BR, Grant M, Borneman T, et al. Family caregiving in cancer pain management. J Palliat Med.1999;2:185–195. [PubMed]
47. Justice AC, Chang CH, Rabeneck L, et al. Clinical importance of provider-reported HIV symptoms compared with patient-report. Med Care. 2001;39:397–408. [PubMed]
48. Neighbor ML, Puntillo K, O’Neill B. Nurse underestimation of patient pain intensity. Acad Emerg Med.1999;6:514. (abstract)
49. Puntillo K, Neighbor M, O’Neil N, et al. Accuracy of emergency nurses in assessment of patients’ pain.Pain Manag Nurs. 2003;4:171–175. [PubMed]
50. Lobchuk MM, Vorauer JD. Family caregiver perspective-taking and accuracy in estimating cancer patient symptom experiences. Soc Sci Med. 2003;57:2379–2384. [PubMed]
51. Lobchuk MM, McClement SE, Daeninck PJ, et al. Asking the right question of informal caregivers about patient symptom experiences: Multiple proxy perspectives and reducing interrater gap. J Pain Symptom Manage. 2007;33:130–145. [PubMed]
52. Lobchuk MM. Concept analysis of perspective-taking: Meeting informal caregiver needs for communication competence and accurate perception. J Adv Nurs. 2006;54:330–341. [PubMed]
53. McPherson CJ, Addington-Hall JM. Judging the quality of care at the end of life: Can proxies provide reliable information? Soc Sci Med. 2003;56:95–109. [PubMed]
54. Horton R. Differences in assessment of symptoms and quality of life between patients with advanced cancer and their specialist palliative care nurses in a home care setting. Palliat Med. 2002;16:488–494.[PubMed]
55. Kutner JS, Kassner CT, Nowels DE. Symptom burden at the end of life: Hospice providers’ perceptions.J Pain Symptom Manage. 2001;21:473–480. [PubMed]
56. Ely EW, Gautam S, Margolin R, et al. The impact of delirium in the intensive care unit on hospital length of stay. Intensive Care Med. 2001;27:1892–1900. [PubMed]
57. Lin SM, Liu CY, Wang CH, et al. The impact of delirium on the survival of mechanically ventilated patients. Crit Care Med. 2004;32:2254–2259. [PubMed]58. Balas MC, Happ MB, Yang W, et al. Outcomes Associated With Delirium in Older Patients in Surgical ICUs. Chest. 2009;135:18–25. [PMC free article] [PubMed]
59. Ely EW, Margolin R, Francis J, et al. Evaluation of delirium in critically ill patients: Validation of the Confusion Assessment Method for the Intensive Care Unit (CAM-ICU) Crit Care Med. 2001;29:1370–1379.[PubMed]
60. Bergeron N, Dubois MJ, Dumont M, et al. Intensive Care Delirium Screening Checklist: Evaluation of a new screening tool. Intensive Care Med. 2001;27:859–864. [PubMed]
2. Stanik-Hutt JA, Soeken KL, Belcher AE, et al. Pain experiences of traumatically injured patients in a critical care setting. Am J Crit Care. 2001;10:252–259. [PubMed]
3. Puntillo KA, White C, Morris AB, et al. Patients’ perceptions and responses to procedural pain: Results from Thunder Project II. Am J Crit Care. 2001;10:238–251. [PubMed]
4. Arroyo-Novoa CM, Figueroa-Ramos MI, Puntillo KA, et al. Pain related to tracheal suctioning in awake acutely and critically ill adults: A descriptive study. Intensive Crit Care Nurs. 2008;24:20–27. [PubMed]
5. Stotts NA, Puntillo K, Bonham Morris A, et al. Wound care pain in hospitalized adult patients. Heart Lung. 2004;33:321–332. [PubMed]
6. Powers J, Bennett SJ. Measurement of dyspnea in patients treated with mechanical ventilation. Am J Crit Care. 1999;8:254–261. [PubMed]
7. Knebel AR, Janson-Bjerklie SL, Malley JD, et al. Comparison of breathing comfort during weaning with two ventilatory modes. Am J Respir Crit Care Med. 1994;149:14–18. [PubMed]
8. Hallenberg B, Bergbom-Engberg I, Haljamäe H. Patients’ experiences of postoperative respirator treatment–influence of anaesthetic and pain treatment regimens. Acta Anaesthesiol Scand. 1990;34:557–562.[PubMed]
9. Riggio RE, Singer RD, Hartman K, et al. Psychological issues in the care of critically-ill respirator patients: Differential perceptions of patients, relatives, and staff. Psychol Rep. 1982;51:363–369. [PubMed]
10. Wilson VS. Identification of stressors related to patients’ psychologic responses to the surgical intensive care unit. Heart Lung. 1987;16:267–273. [PubMed]
11. Cochran J, Ganong LH. A comparison of nurses’ and patients’ perceptions of intensive care unit stressors. J Adv Nurs. 1989;14:1038–1043. [PubMed]
12. Ely EW, Inouye SK, Bernard GR, et al. Delirium in mechanically ventilated patients: Validity and reliability of the confusion assessment method for the intensive care unit (CAM-ICU) JAMA.2001;286:2703–2710. [PubMed]
13. Novaes MA, Knobel E, Bark AM, et al. Stressors in ICU: Perception of the patient, relatives and health care team. Intensive Care Med. 1999;25:1421–1426. [PubMed]
14. Desbiens NA, Mueller-Rizner N, Connors AF, Jr, et al. The symptom burden of seriously ill hospitalized patients. SUPPORT Investigators. Study to Understand Prognoses and Preferences for Outcome and Risks of Treatment. J Pain Symptom Manage. 1999;17:248–255. [PubMed]
15. Nelson JE, Meier DE, Oei EJ, et al. Self-reported symptom experience of critically ill cancer patients receiving intensive care. Crit Care Med. 2001;29:277–282. [PubMed]
16. Puntillo K, Pasero C, Li D, et al. Evaluation of pain in ICU patients. Chest. 2009;135:1069–1074.[PubMed]
17. Hickman SE, Tilden VP, Tolle SW. Family reports of dying patients’ distress: The adaptation of a research tool to assess global symptom distress in the last week of life. J Pain Symptom Manage.2001;22:565–574.[PubMed]
18. Nekolaichuk CL, Bruera E, Spachynski K, et al. A comparison of patient and proxy symptom assessments in advanced cancer patients. Palliat Med. 1999;13:311–323. [PubMed]
19. Sneeuw KC, Aaronson NK, Sprangers MA, et al. Evaluating the quality of life of cancer patients: Assessments by patients, significant others, physicians and nurses. Br J Cancer. 1999;81:87–94.[PMC free article] [PubMed]
20. Lobchuk MM, Kristjanson L, Degner L, et al. Perceptions of symptom distress in lung cancer patients: I. Congruence between patients and primary family caregivers. J Pain Symptom Manage. 1997;14:136–146.[PubMed]
21. Teno JM, Coppola KM. For every numerator, you need a denominator: A simple statement but key to measuring the quality of care of the “dying” J_Pain Symptom Manage. 1999;17:109–113. [PubMed]
22. Strömgren AS, Groenvold M, Sorensen A, et al. Symptom recognition in advanced cancer. A comparison of nursing records against patient self-rating. Acta Anaesthesiol Scand. 2001;45:1080–1085.[PubMed]
23. Strömgren AS, Groenvold M, Pedersen L, et al. Does the medical record cover the symptoms experienced by cancer patients receiving palliative care? A comparison of the record and patient self-rating. J Pain Symptom Manage. 2001;21:189–196. [PubMed]
24. Sneeuw KC, Aaronson NK, Osoba D, et al. The use of significant others as proxy raters of the quality of life of patients with brain cancer. Med Care. 1997;35:490–506. [PubMed]
25. Nekolaichuk CL, Maguire TO, Suarez-Almazor M, et al. Assessing the reliability of patient, nurse, and family caregiver symptom ratings in hospitalized advanced cancer patients. J Clin Oncol. 1999;17:3621–3630.[PubMed]
26. Puntillo KA, Miaskowski C, Kehrle K, et al. Relationship between behavioral and physiological indicators of pain, critical care patients’ self-reports of pain, and opioid administration. Crit Care Med.1997;25:1159–1166.[PubMed]
27. Desbiens NA, Mueller-Rizner N. How well do surrogates assess the pain of seriously ill patients? Crit Care Med. 2000;28:1347–1352. [PubMed]
28. Price DD, Harkins SW, Baker C. Sensory-affective relationships among different types of clinical and experimental pain. Pain. 1987;28:297–307. [PubMed]
29. Broberger E, Tishelman C, von Essen L. Discrepancies and similarities in how patients with lung cancer and their professional and family caregivers assess symptom occurrence and symptom distress. J Pain Symptom Manage. 2005;29:572–583. [PubMed]
30. Knaus WA, Draper EA, Wagner DP, et al. APACHE II: A severity of disease classification system. Crit Care Med. 1985;13:818–829. [PubMed]
31. Knaus WA, Harrell FE, Jr, Lynn J, et al. The SUPPORT prognostic model. Objective estimates of survival for seriously ill hospitalized adults. Study to understand prognoses and preferences for outcomes and risks of treatments. Ann Intern Med. 1995;122:191–203. [PubMed]
32. The SUPPORT Principal Investigators: A controlled trial to improve care for seriously ill hospitalized patients. The study to understand prognoses and preferences for outcomes and risks of treatments (SUPPORT) JAMA. 1995;274:1591–1598. [PubMed]
33. Puntillo KA, Arai S, Cohen NH, et al. Symptoms experienced by intensive care unit patients at high risk of dying. Crit Care Med. 2010;38:2155–2160. [PMC free article] [PubMed]
34. Damiano AM, Bergner M, Draper EA, et al. Reliability of a measure of severity of illness: Acute physiology of chronic health evaluation–II. J Clin Epidemiol. 1992;45:93–101. [PubMed]
35. Devlin JW, Boleski G, Mlynarek M, et al. Motor Activity Assessment Scale: A valid and reliable sedation scale for use with mechanically ventilated patients in an adult surgical intensive care unit. Crit Care Med. 1999;27:1271–1275. [PubMed]
36. Fleiss JL, Levin B, Paik MC. Statistical Methods for Rates and Proportions. New York: John Wiley and Sons; 2003. pp. 218–226.
37. Liang KY, Zeger SL. Longitudinal data analysis using generalized linear models. Biometrika.1986;73:13–22.
38. Hanley JA, Negassa A, Edwardes MD, et al. Statistical analysis of correlated data using generalized estimating equations: An orientation. Am J Epidemiol. 2003;157:364–375. [PubMed]
39. Hemphill JF. Interpreting the magnitudes of correlation coefficients. Am Psychol. 2003;58:78–79.[PubMed]
40. Hox J. Multilevel Analysis: Techniques and Applications. 2. New York: Routledge; 2010. p. 244.
41. Skrondal A, Rabe-Hesketh S. Generalized Latent Variable Modeling: Multilevel, Longitudinal, and Structural Equation Models. Boca Raton, FL: Chapman and Hall/CRC; 2004. pp. 321–348.
42. Hinton J. How reliable are relatives’ retrospective reports of terminal illness? Patients and relatives’ accounts compared. Soc Sci Med. 1996;43:1229–1236. [PubMed]
43. Puntillo KA, Smith D, Arai S, et al. Critical care nurses provide their perspectives of patients’ symptoms in intensive care units. Heart Lung. 2008;37:466–475. [PubMed]
44. Lobchuk MM, Kristjanson L, Degner L, et al. Perception of symptom distress in lung cancer patients: Agreement between patients and their caregiving relatives. Pflege. 1999;12:352–361. [PubMed]
45. Miaskowski C, Zimmer EF, Barrett KM, et al. Differences in patients’ and family caregivers’ perceptions of the pain experience influence patient and caregiver outcomes. Pain. 1997;72:217–226. [PubMed]
46. Ferrell BR, Grant M, Borneman T, et al. Family caregiving in cancer pain management. J Palliat Med.1999;2:185–195. [PubMed]
47. Justice AC, Chang CH, Rabeneck L, et al. Clinical importance of provider-reported HIV symptoms compared with patient-report. Med Care. 2001;39:397–408. [PubMed]
48. Neighbor ML, Puntillo K, O’Neill B. Nurse underestimation of patient pain intensity. Acad Emerg Med.1999;6:514. (abstract)
49. Puntillo K, Neighbor M, O’Neil N, et al. Accuracy of emergency nurses in assessment of patients’ pain.Pain Manag Nurs. 2003;4:171–175. [PubMed]
50. Lobchuk MM, Vorauer JD. Family caregiver perspective-taking and accuracy in estimating cancer patient symptom experiences. Soc Sci Med. 2003;57:2379–2384. [PubMed]
51. Lobchuk MM, McClement SE, Daeninck PJ, et al. Asking the right question of informal caregivers about patient symptom experiences: Multiple proxy perspectives and reducing interrater gap. J Pain Symptom Manage. 2007;33:130–145. [PubMed]
52. Lobchuk MM. Concept analysis of perspective-taking: Meeting informal caregiver needs for communication competence and accurate perception. J Adv Nurs. 2006;54:330–341. [PubMed]
53. McPherson CJ, Addington-Hall JM. Judging the quality of care at the end of life: Can proxies provide reliable information? Soc Sci Med. 2003;56:95–109. [PubMed]
54. Horton R. Differences in assessment of symptoms and quality of life between patients with advanced cancer and their specialist palliative care nurses in a home care setting. Palliat Med. 2002;16:488–494.[PubMed]
55. Kutner JS, Kassner CT, Nowels DE. Symptom burden at the end of life: Hospice providers’ perceptions.J Pain Symptom Manage. 2001;21:473–480. [PubMed]
56. Ely EW, Gautam S, Margolin R, et al. The impact of delirium in the intensive care unit on hospital length of stay. Intensive Care Med. 2001;27:1892–1900. [PubMed]
57. Lin SM, Liu CY, Wang CH, et al. The impact of delirium on the survival of mechanically ventilated patients. Crit Care Med. 2004;32:2254–2259. [PubMed]58. Balas MC, Happ MB, Yang W, et al. Outcomes Associated With Delirium in Older Patients in Surgical ICUs. Chest. 2009;135:18–25. [PMC free article] [PubMed]
59. Ely EW, Margolin R, Francis J, et al. Evaluation of delirium in critically ill patients: Validation of the Confusion Assessment Method for the Intensive Care Unit (CAM-ICU) Crit Care Med. 2001;29:1370–1379.[PubMed]
60. Bergeron N, Dubois MJ, Dumont M, et al. Intensive Care Delirium Screening Checklist: Evaluation of a new screening tool. Intensive Care Med. 2001;27:859–864. [PubMed]
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