This paper documents a systematic database search using the PICO framework to investigate whether early entry into a hospice program leads to better pain management outcomes for terminally ill patients. The author searches CINAHL, Medline, and Cochrane Summaries using primary terms, synonyms, and MeSH vocabulary, refining the clinical question at each stage. The search process demonstrates how iterative keyword selection — including the shift from "terminally ill" to "early entry" — affects both search volume and article relevance. The paper identifies several useful articles and concludes with a refined PICO question supported by evidence from nursing home hospice care research.
The paper exemplifies iterative PICO refinement — the process of adjusting a clinical question based on what search results reveal about how terms are actually used in the medical literature. By documenting why "early admitted" was replaced with "early entry," the author shows how language precision directly affects evidence retrieval quality.
The paper opens by defining the PICO components and primary search terms, then walks through three database searches in sequence (CINAHL, Medline, Cochrane). Each section reports search strategies tried, article counts, useful results found, and a rationale for the next step. The paper closes with identification of the single most relevant article and a reflection on which database proved most useful.
The clinical question posed for this search activity is: "Does early referral of terminally ill patients into a hospice program result in better patient outcomes, particularly with regard to pain management?" Using the PICO framework, the components of this question are identified as follows: the patient group is terminally ill patients; the intervention is terminal illness management; the comparison is the time at which the patient enters hospice care; and the outcome is reduced pain.
The primary search terms identified for this question are hospice and pain management. Synonyms for these terms include in-home care, bereavement care, critical condition, deathbed, palliative, and anesthesia. The MeSH terms are: Hospices, Terminal Care, Pain Management, and Chronic Disease.
Based on the identified synonyms, a better phrasing of the question may be: "Do early-admitted hospice patients have better outcomes regarding pain management?" The reason for this slight revision is that only terminally ill patients can be admitted into hospices, so the term "terminally ill" does not necessarily need to appear in the clinical question itself.
The first database searched was CINAHL. The initial search used the primary research terms placed separately in quotation marks. This produced very vague results with no helpful articles, returning a total of 2,330 papers. The term "terminally ill" was then removed, leaving the other two terms. This caused the article titles to become considerably more relevant, though the total number of articles increased to 14,200. The following useful articles appeared on the first page of results:
Berry, Patricia (1995). Barriers to pain management in hospice: A study of family caregivers. Hospice Journal, 10(4), 19–33.
Fothergill-Bourbonnaise, Frances; Wilson, Jennifer (2006). A comparative study of intensive therapy unit and hospice nurses' knowledge on pain management. Journal of Advanced Nursing, 17(3), 362–372.
Gloth, F. Pain management in older adults: Prevention and treatment. Journal of the American Geriatrics Society, 49(2), 188–199.
Miller, Susan; et al. (2002). Does receipt of hospice care in nursing homes improve the management of pain at the end of life? Journal of the American Geriatrics Society, 50(3), 507–515.
Miller, Susan; et al. (2003). Hospice enrollment and pain assessment and management in nursing homes. Journal of Pain and Symptom Management, 24(3), 791–799.
A search using the synonym phrase "early terminal care" placed in quotation marks returned only three articles, none of which were useful. A subsequent search using the terms "early entry" (in quotation marks) and hospice (without quotation marks) returned 75 studies, several of which were highly relevant, including:
Chow, E.; et al. (2000). How accurate are physicians' clinical predictions of survival and the available prognostic tools in estimating survival times in terminally ill cancer patients? A systematic review. Clinical Oncology, 13(3), 209–218.
Kinzbrunner, Barry (1994). Ethical dilemmas in hospice and palliative care. Supportive Care in Cancer, 3(1), 28–36.
McKinlay, Eileen; McBain, Lynn (2007). Evaluation of the Palliative Care Partnership: a New Zealand solution to the provision of integrated palliative care. The New Zealand Medical Journal, 120(1263).
Following these results, the clinical question was further refined to: "Does early entry into a hospice program result in better pain management?" The change from "early admitted" to "early entry" was made because "entry" yielded far more accurate results, suggesting it is the term more commonly used in the medical literature when referring to admittance into a medical program or department.
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