How well do surrogates assess the pain of seriously ill patients?

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Abstract
To compare pain assessments made by seriously ill hospitalized patients and their surrogates and to understand factors that might lead to reporting differences. Cross-sectional study. Five U.S. teaching hospitals. Patients were 2,645 of 9,105 patients in the Study to Understand Prognoses and Preferences for Outcomes and Risks of Treatments for whom there were both patient and surrogate interviews about pain. The majority of patients had acute respiratory failure, multiple organ system failure with sepsis, exacerbation of chronic obstructive pulmonary disease, and congestive heart failure. None. We queried patients and surrogates by using Likert-type scale questions about the frequency and severity of patients’ pain. Overall, surrogates correctly estimated presence or absence of patients’ pain 73.5% of the time (kappa = 0.47, 95% confidence interval [CI], 0.44, 0.50), overestimating 16.8% of the time and underestimating 9.7% of the time. Exact estimation of the presence and level of pain was considerably poorer, with only 53.0% of surrogates correctly assessing exact level of pain (kappa = 0.31; 95% CI, 0.28, 0.33; weighted kappa = 0.43; 95% CI, 0.41, 0.46). Patients’ reported level of pain, days in hospital before study admission, time interval between patient and surrogate assessment, and study hospital were associated with inaccuracy in surrogates’ estimation of patients’ pain. Family members correctly assess the level of pain of hospitalized patients with moderate success. Further studies are needed to assess the accuracy of assessment of pain by family members compared with that of health professionals, and to determine whether surrogates’ accuracy in estimating patients’ pain can be improved.