How is sepsis treated in a patient who is on comfort care only?

Pangea Reunited, ASN, RN · May 31, 2016

Does anyone know the general guidelines for treatment of sepsis in a patient who has an advanced directive for comfort care only?
TIA!

This varies a lot by region and facility. "Comfort care" in my first location was morphine, ativan and oxygen. Where I'm at now, it's antibiotics, other scheduled medications, a diet, and just about everything else that's not too extreme.

akulahawkRN, ADN, RN, EMT-P · Jun 1, 2016

Does anyone know the general guidelines for treatment of sepsis in a patient who has an advanced directive for comfort care only?
TIA!

It really depends upon the specifics of the advanced directive. I had a "comfort care" patient the other day and it basically allowed us to treat acute problems but no feeding tubes or intubation. So if the patient had sepsis, for instance, we could give antibiotics and fluid but cpap was iffy and intubation was clearly out. Basically as long as the treatment was temporary and not a code, we could do it.

You just have to know what the document and your local policy is on this matter.

calivianya, BSN, RN · Jun 1, 2016

Comfort care = withdrawal of care on my unit. Antibiotics might be used if the infection itself was causing discomfort, i.e. the sepsis came from a UTI and the patient was experiencing burning and urgency. If the infection was killing the patient but not making the patient uncomfortable, there would be no treatment for the sepsis.

KatieMI, BSN, MSN, RN · Jun 2, 2016

Comfort care = care to relieve unpleasant symptoms. Therefore, the symptoms of sepsis that bother patient (fever, thirst, restlessness) are treated with symptomatic meds. Main reason, which is infection, can be treated under some circumstances. I'd seen a poor soul on comfort care with chronic sepsis who had huge carbuncles popping up here and there. They were, apparently, very painful, and so were I&Ded at bedside and irrigated with antibiotics, but antibiotics were not given systemically.

CelticGoddess, BSN, RN · Jun 2, 2016

At my facility, a comfort patient only get's comfort meds, typically Ativan, Morphine or Dilaudid (or a fentanyl drip) and Robinul. If a comfort patient is septic, and is running a fever, we'll give acetaminophen. That's about it. Our goal is to keep them as comfortable as possible.

nutella, MSN, RN · Jun 2, 2016

Does anyone know the general guidelines for treatment of sepsis in a patient who has an advanced directive for comfort care only?
TIA!

There are several things to look at.

1. Advanced directive - meaning what? a POLST ? a Living will? not all states accept a living will for example ...

2. Is is VALID? I run into this problem regularly - patients or family claim that there is an advanced directive but actually turns out it is not or they confuse HCP with POLST. Or the patient is unable to make those decisions (example HCP activated lifelong by one doctor and other doctor lets the patient sign a POLST, which is not valid in that case). Or - worst case - patient is under guardianship but the guardian does not have the right to make end of life decisions. Guardianship trumps HCP and there needs to be a court paper to verify if the guardian is allowed to change the code status for example.

3. What is "comfort care" in your facility? This can vary. Comfort care in a local nursing home does not mean the same as comfort measure only in the hospital.

4. Generally speaking - comfort care focuses on relieving symptoms without treating a cause, which commonly excludes antibiotics and iv fluids. With sepsis - you would medicate for fever, medicate for pain and SOB, anxiety, secretions. You would also provide the regular ADL and emotional support. Spiritual support for pat and family through chaplain.

Just a quick story to illustrate how complicated it can be.

A patient comes in for SOB and has a living will that outlines what the patient would want or not but no POLST . The patient has a HCP form. Now the patient becomes unconscious and has trouble breathing. The physician calls the HCP to update on the decline in status and mentions that the patient presented a living will , which is not recognized in the state. The HCP now requests that "everything be done" and the patient intubated. Although the HCP should be guided by the pat wishes - in that case everybody is afraid to get sued. Patient goes to the ICU, gets intubated. Other family comes and the drama is in progress. Now the HCP decides to make the patient CMO , to extubate and "have him die" as was his original wish since he has cancer from head to toe.

Kitiger, RN · Jun 2, 2016

There are several things to look at.
1. Advanced directive - meaning what? a POLST ? a Living will? not all states accept a living will for example ...
2. Is is VALID? I run into this problem regularly - patients or family claim that there is an advanced directive but actually turns out it is not or they confuse HCP with POLST. Or the patient is unable to make those decisions (example HCP activated lifelong by one doctor and other doctor lets the patient sign a POLST, which is not valid in that case). Or - worst case - patient is under guardianship but the guardian does not have the right to make end of life decisions. Guardianship trumps HCP and there needs to be a court paper to verify if the guardian is allowed to change the code status for example.
3. What is "comfort care" in your facility? This can vary. Comfort care in a local nursing home does not mean the same as comfort measure only in the hospital.
4. Generally speaking - comfort care focuses on relieving symptoms without treating a cause, which commonly excludes antibiotics and iv fluids. With sepsis - you would medicate for fever, medicate for pain and SOB, anxiety, secretions. You would also provide the regular ADL and emotional support. Spiritual support for pat and family through chaplain.
Just a quick story to illustrate how complicated it can be.
A patient comes in for SOB and has a living will that outlines what the patient would want or not but no POLST . The patient has a HCP form. Now the patient becomes unconscious and has trouble breathing. The physician calls the HCP to update on the decline in status and mentions that the patient presented a living will , which is not recognized in the state. The HCP now requests that "everything be done" and the patient intubated. Although the HCP should be guided by the pat wishes - in that case everybody is afraid to get sued. Patient goes to the ICU, gets intubated. Other family comes and the drama is in progress. Now the HCP decides to make the patient CMO , to extubate and "have him die" as was his original wish since he has cancer from head to toe.

OK, I Googled and figured out that CMO means comport measures only, HCP is health care proxy, and POLST is physician's orders for life sustaining treatment.

It surely would help me if you would define your terms. Am I the only one who struggles with this?