Protocol for comfort care

General E. Speaking, RN, RN · Feb 28, 2011

At my hospital it is up to each doc. Usually they write something like Ativan 1 or 2mg q 10-15 minutes PRN and Morphine IV PRN. (With a generous dose prior to extubation)

I haven't seen a protocol. Maybe because each patients needs will be different for end of life care? The PRNs they write are usually sufficient enough to give us the ability to make the patient's final moments comfortable. Might be nice to have something consistent.

How long has this patient been extubated? Does she look uncomfortable? What was her respiration rate? Family present?

Editorial Team / Admin · Feb 28, 2011

Thank you for asking about this.

When my mom was terminal (malignant IVC syndrome) she was given a Fentanyl patch and also a scopolamine patch.

VS were taken sparingly.

She was comfortable.

I only had one question, when the staff continued to perform accuchecks and administer glucose IV for low blood sugar.

I requested they stop performing the accuchecks.

Later I sent a letter to the hospital thanking the nurses for their care and gently suggested they review their palliative care protocol to prevent unnecessary procedures/pain.

Thank you again for asking about this. :)

General E. Speaking, RN, RN · Feb 28, 2011

Thank you for asking about this.
When my mom was terminal (malignant IVC syndrome) she was given a Fentanyl patch and also a scopolamine patch.
VS were taken sparingly.
She was comfortable.
I only had one question, when the staff continued to perform accuchecks and administer glucose IV for low blood sugar.
I requested they stop performing the accuchecks.
Later I sent a letter to the hospital thanking the nurses for their care and gently suggested they review their palliative care protocol to prevent unnecessary procedures/pain.
Thank you again for asking about this. :)

I am sorry about your mother. :hug: End of life care is often overlooked and very important. We have a Palliative Care team that can be consulted. Mainly, it is for spiritual-type support for the patient and family. I don't believe that it affects actual hands on care, such as stopping treatments and things. My boss is on the team and I am going to ask her.

If they are changed over to Hospice status while in the hospital, then everything not related to comfort care is stopped.

MomRN0913 · Feb 28, 2011

This woman is young, 40 years old. It's a very, very sad story. The husband and family is present. I think the husband thought she would die pretty fast. I told him it could be days or weeks. Today it has officially been 1 week. She is young, the heart is strong. She also had cancer and was on oxycontin for 3 years and dilaudid IV for a while. But she appears comfortable. In his mind he wanted to end her suffering, which means he let go of her, knows she will die and can't stand waiting for her to die. But we make comfortable, we can't euthanize. She has been in a vegetative state since suffering cardiac arrest.

No vital signs are being taken. Well, except I found out they put her on a cardiac monitor to see have record of death. I think that might be driving the family nuts too, so I want it off.

It's so sad. Especially since the husband is clearly losing his mind now. The next step is she will have to go to hospice and he will freak because he doesn't want her moved.

MomRN0913 · Feb 28, 2011

Dianah, you did a wonderful thing for your mom. I am sorry for your loss. Palliative care is very, very important and often overlooked. The greatest gift you could give a love one is a comfortable passing.

ckh23, BSN, RN · Feb 28, 2011

My last facility I worked at has a end of life protocol where a morphine gtt is started and titrated. The protocol also lists out specific things to be done or not to be done.

loriangel14, RN · Feb 28, 2011

The doctor on the floor where I work writes the palliative orders.Usually they are 2-10mg morphine q15 min (we start SC ports and DC IVs), 1-2 mg Ativan q4, and a scapolomine patch. These orders usually don't vary. We never take VS if they are palliative.

SolaireSolstice, BSN, RN · Feb 28, 2011

There is no protocol for the facility I work for either. Every MD seems to have their own idea about what to do. Most simply remove all medications except prns, start a narcotic drip "RN titrate to comfort", stop all lab draws. Vitals are "as per unit" and I usually tell the PCA to not, just to peek in and let me know if they need anything.

However, what I have experienced is that once the patient is made DNR and comfort care, the patient often moves into a state where once they aren't being "messed" with anymore, they seem to last much longer than we thought they would when we were worried they would code. I always say it's because we've finally let them alone.

ErinS, BSN, RN · Feb 28, 2011

Our hospice admit orders include:

Morphine 2-8 mg q hour prn

Ativan (or versed) 1-2mg q 2 hours prn

Haldol 1-2 mg q 4 hours prn

Dc vs, cardiac monitor, resp therapy, wean off O2

In my experience, young people can take a very long time to die (strong heart, strong lungs). We always treat someone who is comatose for possible anxiety- this is not a symptom that is easily discernible on someone's face. This is the hardest kind of death- the one that takes forever. I usually just encourage the family to keep talking to pt- I personally believe there is a reason for why pt's die the way they do (whether fast or slow). Enjoy the time they have left, as difficult as it is.

gracieD · Feb 28, 2011

While this may not speak to a protocol, you may consider more psychosocial/spiritual reasons that are 'delaying' her passing. I have heard many stories of patients waiting for certain family members to be ready, to be present, or even to leave the bedside. Just a few weeks ago I had a patient who was placed on comfort care, extubated, started on a morphine drip, and simply held on. Her family was at her bedside for over 24 hours straight. I suggested that perhaps she didn't want her family to be present when she passed on, so they decided to wait in the waiting room. It wasn't thirty minutes after they left the room that she passed, and they were so relieved. This could be something that you could explore that you don't even need a protocol for!

BrookeeLou_RN · Feb 28, 2011

Both my parents died in 2010 at home with me as sole caregiver with Hospice care. Dad in FL had roxanal sublingual and ativan liquid which was not quite right for him as his passing was rather difficult and he seemed quite uncomfortable. My mother who came to live IN TN with me, was given SQ lines of morphine and then ativan. I was not familiar with this but found it highly successful and her passing was calm and peaceful. So I am truly impressed with sq lines in comfortcare/hospice. They died 6 mos apart but obviously different hospices have different protocols.