Exact difference between comfort measures & hospice?

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    What is the difference between Comfort Measures Only, Hospice, DNR...What is the exact difference? ( I know some, but I'll appreciate if someone can clearly explain it.) Thanks a lot in advance.

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  2. 10 Comments...

  3. 17
    comfort measures only: this means no other intervention or medications which are not related to making the patient more comfortable. that's no antibiotics, no more lab work or diagnostic studies, therapies, or procedures; usually diet as desired (if the patient can take p.o), and oxygen, treatments, and medications to promote comfort are given. note that in the dying patient, iv hydration causes more distress by preventing the natural decrease of secretions and urine, so ivs are usually stopped and discontinued. thirst is not an issue with the actively dying, but nausea and vomiting and wet lungs with shortness of breath are.

    dnr: do not resuscitate. no cpr, no intubation (although sometimes this last has to be specified), no "code meds." sometimes notes specifics, like, "no intubation," "no pressors," "no external pacing," and the like. may or may not include "comfort measures only," so be sure the md knows what's wanted.

    hospice: hospice is a service which is most often paid by medicare but whose services are generally duplicated by non-medicare insurance if the patient isn't eligible for medicare.
    to be eligible for hospice, the person must be terminally ill with a condition that can reasonably be expected to cause death within six months if not treated, and treatment (beyond palliative care, symptom management for comfort) is not wanted. this is a really nice little site with pdf worksheets for different diagnoses (like alzheimer's, adult failure-to-thrive syndrome, cv, renal, hepatic, hiv, etc.) and functional performance scales to help you see how to determine whether death may be expected within six months and meeting hospice criteria. http://wecareho.startlogic.com/admissionb.html/
    here's the info for hepatic disease as an example:
    lcd for hospice – liver disease (311)
    patients will be considered to be in the terminal stage of liver disease (life expectancy of six months or less) if they meet the following criteria (1 and 2 must be present; factors from 3 will lend supporting documentation):
    1. the patient should show both a and b:
    a. prothrombin time prolonged more than 5 seconds over control, or international
    normalized ratio (inr)> 1.5
    b. serum albumin <2.5 gm/d1
    2. end stage liver disease is present and the patient shows at least one of the following:
    a. ascites, refractory to treatment or patient non-complaint
    b. spontaneous bacterial peritonitis
    c. hepatorenal syndrome (elevated creatinine and bun with oliguria (<400ml/day)
    and urine sodium concentration <10 meq/l)
    d. hepatic encephalopathy, refractory to treatment, or patient non-complaint
    e. recurrent variceal bleeding, despite intensive therapy
    3. documentation of the following factors will support eligibility for hospice care:
    a. progressive malnutrition
    b. muscle wasting with reduced strength and endurance
    c. continued active alcoholism (> 80 gm ethanol/day)
    d. hepatocellular carcinoma
    e. hbsag (hepatitis b) positivity
    f. hepatitis c refractory to interferon treatment
    patients awaiting liver transplant who otherwise fit the above criteria may be certified for the medicare hospice benefit, but if a donor organ is procured, the patient must be discharged from hospice.

    it is a very regulated insurance product, which includes very specific services for patient and family (defined as whoever the patient says they want included). hospice cases are audited q3months to see that the patient still meets criteria for services. people can be on hospice for as long as necessary, though, so long as they meet criteria. people can "flunk" hospice and get better; if they then decline and meet criteria again, they can go back in service with no wait period and no penalties. i like to say it's one of the best federal benefits ever put into place.
    Last edit by GrnTea on Jun 4, '11 : Reason: additonal info
    tewdles, mama_d, digoe74, and 14 others like this.
  4. 0
    @GrnTea: WOW! Well explained...Txs a alot!
  5. 3
    Quote from payang0722
    what is the difference between comfort measures only, hospice, dnr...what is the exact difference? ( i know some, but i'll appreciate if someone can clearly explain it.) thanks a lot in advance.

    in my state of massachusetts there are very specific rules and regs for comfort care.

    http://www.mass.gov/?pageid=eohhs2su...am&sid=eeohhs2

    all comfort cares are dnr (do not resuscitate) patients. this was developed because ems personell were required to intervene with all methods available to them including intubation because the law and their protocols did not recognize hospital dnr orders. comfort care patients wear a special bracelt not unlike a hospital band that designates them as cc. ems personell recognize this and will transport patients without intervention and treatment. comfort care is and must be a dnr and these patients are recieving no interventions, labs treatment..... except those approved by the family for the patients comfort only...ie: pain meds or morphine gtts sometimes iv fluids but that is usually to keep the morphine infusing and at time oxygen. all meds anitbiotics treatments are stopped....death is inevitable and imminent.

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    originally posted by espikey
    in reading this thread, i'm a bit confused- what is the difference between comfort care and hospice
    not much really. the new term being tossed around these days is end of life care. here are some links to information about it:
    http://allnurses.com/geriatric-nurse...958-page2.html


    a hospice patient, is a patient with a terminal diagnosis to set in motion of services for the family to assist with the dying process and counseling services made available. it's a way to get everyone on the same page so to speak of the grim prognosis, assist with end of life planning, obtaining information and services for the patient and education for everyone. the terminology was developed to obtain reinbursement for services for insurance companies and medicare. a hospice patient does not need to be, and isn't always, a dnr. this is a patient with a terminal/grim prognosis but if they want all heroic measures taken until the end it is their choice. so they are terminal and usually still recieving treatment, meds, interventions, chemo, maybe a dnr but not always a dnr.

    http://www.nlm.nih.gov/medlineplus/hospicecare.html


    do not resuscitate is a patient for whatever reason does not want heroic measuers taken. they usually have some terminal or grave prognosis but not always. a copd patient may want everything done except intubation because they don't want to live on a vent. dnr's may specify what they do not want ie: to be placed on life support... but wish interventions to still be performed like surgeries,meds,antibiotics, insulin and have medical care up to but not including cpr, drugs, intubation, ventilation. a dnr may specify what interventions are desired for each individual patient. a patient may want to be coded but no intubation. some patient don't want cpr (yes it's a waste of time usually) but want meds and defib. some want meds and no defib. a dnr has also been refered to as a living will. but... not all states recognize a written will. a dnr patient does not need to be on hospice or be a comfort care. a dnr is only recognized with in the medical facility that orders it and must be re-written and renewed for each facility and every 3 days when admitted. it is not recognized by ems personel. a living will "advanced directive" is not recognized by every state so you must check with you state you reside....even if you have a living will or advance directive the state doen't have to recognize it....it's purpose is only so they surving family is aware of your wishes.

    http://www.faulknerhospital.org/dnr_orders.html below a summary

    understanding do not resuscitate orders (dnr)

    what are dnr orders?
    dnr means "do not resuscitate." dnr orders are written instructions from a physician telling health care providers not to perform cardiopulmonary resuscitation (cpr). cpr uses mouth-to-mouth or machine breathing and chest compressions to restore the work of the heart and lungs when someone's heart or breathing has stopped. it is an emergency rescue technique that was developed to save the life of people who are generally in good health.
    note: if you do not have a dnr orders, health care providers will begin cpr in an emergency.
    frequently asked questions
    cpr is a vigorous emergency procedure and it is not always successful. experience has shown that cpr does not restore breathing and heart function in patients who have widespread cancer, widespread infection or other terminal illness.
    a patient may not want cpr attempted when:
    there is no medical benefit expected. cpr wasn't meant for people who are terminally ill or have severe health problems. cpr is not likely to be successful for these people.
    quality of life would suffer. sometimes cpr is only partly successful. though the patient survives, they may suffer damage to the brain or other organs or permanently may be dependent on a machine to breathe. this can be particularly true for the elderly and very frail.
    death is expected soon. persons with terminal illness may not want aggressive interventions but prefer a natural peaceful death.
    advanced cpr offers additional interventions which can include:

    intubation - the insertion of a tube into the mouth or nose to help with breathing.
    mechanical ventilation - the use of a machine to move air into the lungs.
    medications - given through a vein, drugs can help with blood pressure regulation, heart rhythm, and blood flow.
    cardioversion - the use of a controlled electrical shock to change heart rhythm.

    glossary of terms
    cardiac chest compression:
    the force applied by pressing with both arms over the mid-chest to restore circulation of blood by the heart. because a great deal of force is needed, there can be injury to the surrounding area as a result.
    cpr:
    cardiopulmonary resuscitation: the vigorous emergency procedure to restore heart and lung function in someone whose heart or lungs have stopped working. basic cpr involves chest compression and mouth-to-mouth breathing. advanced cpr includes the use of medications to regulate blood pressure and heart rhythm, controlled electrical shock to change heart rhythm, and intubation and mechanical support of breathing.
    dnr order:
    the physician's order to withhold resuscitation. no cpr.
    dph comfort care/dnr:
    the massachusetts department of public health document that verifies to emergency medical personnel that the person does not want resuscitation.
    cardioversion or defibrillation:
    the use of controlled electrical shock to treat certain kinds of heart rhythm problems.
    intubation:
    a tube inserted through the mouth or nose to open the person's airway to assist with breathing. intubation prevents a patient from talking or eating by mouth.
    mechanical ventilation:
    the use of a machine that pumps air into the lungs of a person who is unable to breathe on his/her own.
    medications for advance life support:
    the use of very potent medications given through the veins that help to correct problems with blood pressure ("pressors"), heart rate and rhythm.
    resuscitation:
    the use of basic or advanced life support treatments in an emergency situation begun when someone has stopped breathing or whose heart has stopped beating.


    it's a complicated issue as you can see i hope this helps.......:redpinkhe
    Chin up, payang0722, and tyvin like this.
  6. 0
    Basically the way i see it is that Comfort cares are kind of when death is going to happen soon. all medications are stopped (except antianxiety or pain medcations). nothing is done to prolong their life. For example, we had a patient come in with sepsis and was not responding to anything we were doing. It was difficult to even maintain oxygen sats in the 80's. She was a DNR-DNI so we couldnt intubate (normally we would in this situation). She did end up being comfort cares due to her code status and nothing else we could do. It had to be the families decision to put her on comfort cares because of the state she was in she was unable to make that decision.

    Hospice is the same concept, but more long-term. Like if someone was diagnosed to end stage renal failure and doesnt want treatment. They may be placed on hospice. Hospice can be the patient's decision.
  7. 2
    My goodness gracious; after that what can I say but excellent work Esme12 and GrnTea. Outstanding!
    Chin up and payang0722 like this.
  8. 1
    Quote from tyvin
    My goodness gracious; after that what can I say but excellent work Esme12 and GrnTea. Outstanding!

    tyvin likes this.
  9. 1
    I admire all of you wonderful nurses with tons of experiences and knowledge. I bow my head.
    Esme12 likes this.
  10. 1
    @tyvin: Indeed Excellent Job from the 2!!!
    Esme12 likes this.
  11. 2
    I'm going to save this thread as it has invaluable information. I am finding more and more that my friends need this information for their aging relatives. Good Job!
    Chin up and merlee like this.


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