Pediatrics. As always, CRNAs need to be meticulous and make sure their pain assessment and subsequent administration of medications to pediatric patients is age appropriate. Often the oral or sublingual route is preferred in children to avoid IV access, which may not be available (Himelstein, 2006).
Pain management techniques
Neuraxial. When opioid therapy fails, palliative care physicians will consult anesthesia for pain management recommendations. Neuraxial techniques and nerve blocks are shown in the literature to be effective adjuncts to pharmacologic pain management in both adult and pediatric palliative care patients. For neuraxial techniques, intrathecal infusions are recommended with straight local anesthetics (LA) or a combination
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Terminally ill patients may present to the OR for palliative surgery. It is important for CRNAs to have a thorough and extensive discussion with the patient, the patient’s surrogate, and the surgical team regarding anesthetic and surgical goals. This discussion should provide clarification as to whether surgical intervention or medical symptom management is the best option to treat the offending symptoms (Mercadante & Giarratano, 2012).
DNR orders are a controversial topic among anesthesia providers. CRNAs may also face an Allow Natural Death (AND) statement. CRNAs should always discuss DNR orders with the patient or their proxy prior to surgery especially since they were not part of the original discussion about resuscitation.
Some hospitals have a policy to routinely suspend DNR orders prior to surgery, however this becomes a sensitive issue when dealing with hospice or palliative care patients presenting for surgery. Not all hospice patients have DNR orders, and likewise, just because a DNR order exists, should it blindly be followed when presenting to the OR? Scott & Garvin (2012) recommend that healthcare providers treat each DNR order individually versus following a universal hospital