Transition to Comfort Care in the ICU: Bedside Monitor On or Off?

[RNerd81]

Recently, I had a new nurse approach me and pose this question: How do I shut off all of my bedside alarms but keep the data on the screen? At first I wondered why in the world the nurse would want to do this, and questioned the quality of her orientation...but she has been a stellar nurse since the day she started, so I listened further...here was the scenario: A patient's family (surrogate for patient, who was comatose) had just transitioned to comfort care after making the decision to stop aggressive allopathic measures. The new nurse initially put the patient's bedside monitor in a "visit" mode in which the data can be seen from outside the room on the central monitor, but in the room, the screen says "visit". Our Comfort Care Order Set actually stipulates that all unnecessary monitoring be removed. This is the first question...what is "unnecessary monitoring"? Secondly, the family requested that the bedside monitor be turned back on, so they could see the rhythm, pulse oximeter, respiratory waveform, and blood pressure. But they, and the nurse, did not want the alarms going off as the patient deteriorated. Would you have honored this request?

[umcRN, BSN, RN]

We have a "comfort care" mode built into our monitors. It turns all the vitals/numbers on the screen purple, no alarms will sound but if something drops below your limit (which we can change in cases such as this) it will alarm to our phone.

This is how I have always experienced it in my three years as nurse. Now recently there was a patient, long known to our unit and the nurse who had him completely turned his monitor off and removed all the leads when care was withdrawn. He lingered for a few days and nurses did "spot checks" with the sat probe as well as leaving him on the pulse ox on comfort care mode when his parents took short naps. He was otherwise held by family members the entire time and they were watching his breathing and would call the nurse over if they got concerned.

Not seeing this practiced before I was a little shocked but people argued that since care had been withdrawn technically he could have been discharged if the parents chose to take him home. No one questioned it and the docs were ok with it.

Obviously of course it also depends on what your unit/hospital policies are and some may need a differentiation between "comfort care" and "withdrawal of care". I also try to encourage family members to focus their attention on their loved one and not on the monitors but if the family is insistent on it I would leave it on with no alarms. It is their moment and if they need to see the numbers as proof of a loved ones death who am I to deny them of that?

As far as "unecessary monitoring" I would say ditch the blood pressure & CVP and other invasive monitoring (and take the a-line out, if its comfort care labs and gasses shouldn't be being drawn). I think a sat probe would be sufficient, you get get sats & HR. You can see if they're breathing by looking at them and if they stop breathing it will be evident by the other numbers. Also PEA can show up on the cardiac leads which can be very confusing and difficult for families to understand if the patient doesn't have a pulse (pacer spikes will also show up regardless of cardiac status)

[EMTtoRNinVA, MSN, RN]

We too have a "Comfort" setting on our monitors that allows you to turn off all alarms and it turns off the in room monitor, but monitoring still shows up on the hallway units and the central station.

[RNerd81]

So, do you question the motivation of the family for wanting the monitor on? Do you think it's morbid curiosity? If the monitor is on, does that detract from a "good" death? Does having the monitor on add anything to the dying experience in the ICU?

[umcRN, BSN, RN]

So, do you question the motivation of the family for wanting the monitor on? Do you think it's morbid curiosity? If the monitor is on, does that detract from a "good" death? Does having the monitor on add anything to the dying experience in the ICU?

Morbid curiosity? I don't think so. Having never witnessed a close family member of my owns death but observing far too many parents/families going through the loss of their child I think it is a completely individual experience and what each family needs to come to terms with their loved ones death is going to vary. While one family may like as natural a death as possible - no monitors, tubes, meds etc, another might need to see the "proof" of their loved ones decline. I don't think it changes whether a death is "good" or not. I think the important thing is that the patient is comfortable and that the family feels supported in their time of need. If they need to see the monitor to gain their own closure then so be it, they are the ones who will spend the rest of their lives with this memory.