Comfort Measures ONLY

Virgo_RN, BSN, RN · Feb 5, 2010

They do, at my hospital. There is a comfort measures protocol sheet that the doctor fills out, with check boxes and blank spaces next to different interventions that the doctor selects.

Bill E. Rubin · Feb 5, 2010

At our hospital, treatment under CMO is usually under the direction of the Palliative Care team. I have made suggestions at times, most have been heeded. For example, I suggested an order for a foley for a woman for whom rotating and moving her to change frequent wet diapers (she was on a Lasix drip) was causing her pain.

tewdles, RN · Feb 5, 2010

What exactly constitutes this?And since you need a physician's order for oxygen, should this be considered a "within nurses' discretion for comfort measures. And why not just the physician or hospital write what the comfort measures should consist of or not.

Comfort measures are generally outlined in standing order sets within the hospital. In the absence of standing orders signed by the MD, specific orders should be written.

Comfort orders generally include things like, no routine lab draws, discontinuation of routine VS checks especially during the night, diet as tolerated, O2 for comfort, and liberalized medication plans for pain, anxiety, nausea, etc. Foley catheters are often ordered for patient dignity and comfort and are provided only if the patient or the family agree. Initiation of the specific elements of the comfort orders is based upon the assessment of the RN and does not require the notification of the MD when they are used. Every attempt is made to remove all noxious interactions which are not absolutely required for the well being of the patient. The focus of the care becomes comfort rather than diagnostic or curative.

Comfort care orders may include use of some medications in a fashion which some nurses may not be familiar or comfortable. For instance, use of morphine for dyspnea may be new to some med surg nurses or use of haloperidol for nausea may be unfamiliar.

Frequently medications which are not critical to the immediate comfort of the patient are discontinued.

In the hospital setting family visitation hours are often liberalized to allow family nearly unlimited access to their loved one in the final hours/days.

classicdame, MSN, EdD · Feb 5, 2010

in some states the term "palliative care" has to be used in the order, or there may be a risk of MD & nurse not providing the appropriate standard of care. I would bring this to the attention of the compliance/risk mgmt person or CNO because an order for "comfort measures" is not specific enough. The MD could order "Palliative Care protocol", if you have one, and that would give you a list of the standards for that order. Otherwise - you are out on a limb in my humble opinion. After all, isn't ALL our measures for comfort?

Bill E. Rubin · Feb 5, 2010

deleted duplicate post

DLS_PMHNP, MSN, RN, NP · Feb 6, 2010

. For example, I suggested an order for a foley for a woman for whom rotating and moving her to change frequent wet diapers (she was on a Lasix drip) was causing her pain.

That's great that you advocated for your pt, cityhawk!

Please make sure you refer to "diapers" as briefs when working in the clincial setting (unless you are dealing with young children). It is a degrading and negative term when referring to the elderly, especially those toward the end of their lives. It does nothing to help preserve their dignity.

this is a big pet peeve of mine; and I'm sorry if my post offended you in any way.

Best, :nurse:

Diane, RN

loriangel14, RN · Feb 6, 2010

Comfort measures are generally outlined in standing order sets within the hospital. In the absence of standing orders signed by the MD, specific orders should be written.
Comfort orders generally include things like, no routine lab draws, discontinuation of routine VS checks especially during the night, diet as tolerated, O2 for comfort, and liberalized medication plans for pain, anxiety, nausea, etc. Foley catheters are often ordered for patient dignity and comfort and are provided only if the patient or the family agree. Initiation of the specific elements of the comfort orders is based upon the assessment of the RN and does not require the notification of the MD when they are used. Every attempt is made to remove all noxious interactions which are not absolutely required for the well being of the patient. The focus of the care becomes comfort rather than diagnostic or curative.
Comfort care orders may include use of some medications in a fashion which some nurses may not be familiar or comfortable. For instance, use of morphine for dyspnea may be new to some med surg nurses or use of haloperidol for nausea may be unfamiliar.
Frequently medications which are not critical to the immediate comfort of the patient are discontinued.
In the hospital setting family visitation hours are often liberalized to allow family nearly unlimited access to their loved one in the final hours/days.

That is exactly how it unfolds where I work. It is such a relief to not have bother the doctor for every step we want to take. We just assess and then do whatever we need to do. Our palliative patients usually are given an order for morphine 1-10mg q15min long before it is needed so we are ready. We do frequently use morphine for dypnea.

tewdles, RN · Feb 6, 2010

in some states the term "palliative care" has to be used in the order, or there may be a risk of MD & nurse not providing the appropriate standard of care. I would bring this to the attention of the compliance/risk mgmt person or CNO because an order for "comfort measures" is not specific enough. The MD could order "Palliative Care protocol", if you have one, and that would give you a list of the standards for that order. Otherwise - you are out on a limb in my humble opinion. After all, isn't ALL our measures for comfort?

I completely agree with the use of palliative care rather than comfort measures in all official documents. It is true that all order sets I have ever seen, or worked with, use the more precise terminology while the staff commonly refer to them as comfort orders or similar. This is an excellent distinction that may well save someone some grief...KUDOS!

Oh how I wish all measures in health care were for comfort. Unfortunately, I believe there are far too many people who are receiving care which is motivated by interest in things other than comfort, particularly in the last decade of life. Too many choices are made out of fear...on the part of patients, families, and health care providers. Of course, it is easy for me to see this, because I work with people at the end of their lives...so all of my vision is retrospective.

StrwbryblndRN · Feb 6, 2010

Just a funny side note. I agree with Diane in regards to referring diapers as briefs. I have done that and then the pt will look at me confused and ask, "you mean the diaper?". This has happened many times and I end up using whatever term the pt uses so as not to confuse my already confused pt's. :)

rachelgeorgina · Feb 6, 2010

Interesting question - what about when a particular comfort measure is also causing discomfort?

For example: pt with end stage respiratory failure/COPD elects not to be intubated/ventilated and has used CPAP in the past to control work of breathing, CO2 retention etc. CPAP is now implemented to relieve shortness of breath, excess work of breathing etc and allow the patient to spend her remaining time with family (without the CPAP she would deteriorate much faster.) However, the CPAP is causing incredible discomfort - feelings of suffocation, drowning and so forth.

What would the nurse be able to do here?

RN1981 · Feb 6, 2010

I'm a hospice nurse and we also have a list of standing orders under our Medical Director. But we're a home care team and we're basically out there on our own in the home and we don't have an MD around. So it's really nice to be able to order things such as Oxygen and Benadryl and the like without trying to phone an MD for every little thing.