I recently changed jobs from one hospital to another. I am baffled by many differences and one of them is "comfort care".
At my old hospital, patient who were on comfort care were kept comfortable. No vital signs, no neuro checks, usually only pain and anxiety medications were given. At my new hospital, a patient is deemed "comfort care" but its obviously in name only. Vitals are done, regular medications are given. There is virtually NOTHING different from the care we would give any other patient.
Comfort care usually includes no vitals (except per family request), no labs, no tests, hourly meds available for pain and sedation. Our staff does turn the patient q2 and do mouth care unless either visibly agitates or family requests that we do not. We get a lot of our own comfort care patients, as I work in oncology, as well as many patients from the ICUs whose families elect comfort measures.
If a patient at the facility that I work at is placed on comfort care the Dr. will typically D/C vitals, labs, scheduled meds, and anything else that may be invasive. However, I have had two patients in recent months who elected to receive their BP meds and a few other scheduled pills because it set their mind at ease more than anything else. Eventually the patients were unable to take PO meds and they were then D/C'd.
Comfort care is always discussed with the family as usually it means that someone is passing on. A DNR is initiated and I will usually recommend O2 prn, suction prn, pain/comfort/antipyretic meds prn, scop patches prn and personal meds prn that the patient/family/MD feel are still necessary. Food and Abx are dependent on the situation. It's true there is research that indicates that fluids are better withheld but that's up to the family/MD/patient/type of fluid.
With comfort care essentials, it's better to have the prns already on board other then wait until they need it. Just because you have PRN orders doesn't mean you have to use them either.
Vitals are dependent on the situation as well. You can't blanket "Comfort Care" into one thing because each situation is different. Some people go into a coma and pass on while others are awake and aware right up until the time they pass. I rarely do BP, but will document apical & rr and basic nursing assessment are sufficient in most cases.
I always initiate my version of comfort care with the MDs because it's too late to order suction when the person is choking to death; though in an emergency situation you certainly wouldn't let someone drown in their own fluids now would you? I just don't know; I've met and worked with some pretty scary RNs .
It's comfort care, not continuation of life; that doesn't mean you withhold it all. Whatever makes the patient comfortable. Many times, they don't require anything at all. Also, if you don't turn them, aren't they going to develop a skin concern? Some of these people hold on for days, sometimes weeks. Call me crazy, but you don't need to do too much to change the position on someone who is passing on (pillows). This also goes for hygiene and oral care.
Put yourself in their position and think...what would make me more comfortable... It is an honor and a privilege to guide a person through the process of passing on. You are assisting someone on the last journey of their life. It's a skill that needs to be learned with much reverence and respect and shouldn't be taken lightly.
Comfort care is always discussed with the family as usually it means that someone is passing on. A DNR is initiated and I will usually recommend O2 prn suction prn, pain/comfort/antipyretic meds prn, scop patches prn and personal meds prn that the patient/family/MD feel are still necessary. Food and Abx are dependent on the situation. It's true there is research that indicates that fluids are better withheld but that's up to the family/MD/patient/type of fluid. With comfort care essentials, it's better to have the prns already on board other then wait until they need it. Just because you have PRN orders doesn't mean you have to use them either. Vitals are dependent on the situation as well. You can't blanket "Comfort Care" into one thing because each situation is different. Some people go into a coma and pass on while others are awake and aware right up until the time they pass. I rarely do BP, but will document apical & rr and basic nursing assessment are sufficient in most cases. I always initiate my version of comfort care with the MDs because it's too late to order suction when the person is choking to death; though in an emergency situation you certainly wouldn't let someone drown in their own fluids now would you? I just don't know; I've met and worked with some pretty scary RNs . It's comfort care, not continuation of life; that doesn't mean you withhold it all. Whatever makes the patient comfortable. Many times, they don't require anything at all. Also, if you don't turn them, aren't they going to develop a skin concern? Some of these people hold on for days, sometimes weeks. Call me crazy, but you don't need to do too much to change the position on someone who is passing on (pillows). This also goes for hygiene and oral care. Put yourself in their position and think...what would make me more comfortable... It is an honor and a privilege to guide a person through the process of passing on. You are assisting someone on the last journey of their life. It's a skill that needs to be learned with much reverence and respect and shouldn't be taken lightly.[/quote']
Specializes in orthopedic/trauma, Informatics, diabetes.
We don't usually get many comfort care, but the ones we have had, our doctors are fabulous, the give the order for comfort care and that usually is drip or morphine or fentanyl, ativan or equivalent. The docs and residents are in and out regularly to monitor and speak with family so we, as nurses can tell what we see, support the family and spend time with the patient if we can. Our patients are treated with dignity and respect and we work very closely as a team to make sure patient is comfortable and family understands. We have chaplains on staff and social workers. I have had 2 experiences in a year of comfort care and I adore the doctors that deal with the palliative care. They are very special.
Only things needed for comfort here. Pain meds, nausea meds, anxiolytics, maybe atropine or scopolamine for secretions. No vitals, labs, or assessments. Turning, positioning, and suctioning only as needed for comfort. Oral care as tolerated. DNR/DNI.
Specializes in NICU, PICU, Transport, L&D, Hospice.
CrazierThanYou,
It sounds like you could facilitate a very meaningful process change for your facility. Gather some information and go to your department manager and the medical staff with some suggestions to improve care for your patients. If there is some standardization of practice and expectation for care the overall care of dying patients will be improved, in my experience.
There are some wonderful comments here, what a great opportunity to develop protocols and policy. Much of what you ask is based on your state BON and the facility you work for. There needs to be policies. A DNR does not mean do not treat. Palliative care patients do not necessarily have DNR orders. Comfort measures do not mean no care. You have been given an opportunity to deliver a gift to your facility. A door was opened just for you, and you must choose if you are going to enter it. Good Luck
All of our doctors are pretty much on the same page as far as comfort care is concerned. Everything is stopped except O2 and meds for pain/anxiety. Our patients are usually on a morphine PCA continuous rate and we can adjust the rate if the patient appears to be in pain, anxious, or SOB. Sometimes a family member will come out and ask if we will give more medicine to make the patient comfortable. Our policy states we must look at the patient at least every 2 hrs and do vital signs once a day. Once the patient is on comfort care we don't restrict visitors in the room. We do however, ask the visitors to leave the room if we need to do anything for the patient: turning, suctioning, cleaning.
Old Hospital: Morphine, ativan and oxygen, patient very likely to have been recently extubated, vital signs (if taken) likely to be unstable, patient very likely to die before shift is over
New Hospital: ambulatory, oriented 60 year old being treated for a UTI who happens to have a DNR form on file
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grandpaj
206 Posts
Comfort care usually includes no vitals (except per family request), no labs, no tests, hourly meds available for pain and sedation. Our staff does turn the patient q2 and do mouth care unless either visibly agitates or family requests that we do not. We get a lot of our own comfort care patients, as I work in oncology, as well as many patients from the ICUs whose families elect comfort measures.