I read with interest the article by Al Darwish and colleauges. First, I congratulate the authors for their rigorous scientific method. Conversations about the issues disscussed in the article will help critical care nurses choose the best available pain assessment tools.

Proper assessment by nurses of pain is essential for the care of nonverbal patients, particularly ventilator-dependent ones. Unfortunately, no gold standard tool for optimal pain assessment exists, resulting in nurses underestimating the severity of pain in nonverbal patients. Several behavioral indicators (eg, BPS, CPOT, the Campbell scale) are recommended for assessment of pain in critically ill nonverbal patients. These tools have some limitations, including the limited applicability in critical care settings and limited comparability with similar tools used for verbal patients.2,3  Although Al Darwish and colleagues found BPS more reliable, valid, and sensitive for pain assessment in nonverbal...

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