Article Figures & Data
Figures
- Figure 1
Care of a person at the end of life.
Tables
Statement goal Sample statements Building trust You’re important to us.
We want to speak truthfully so that we can work together, even when that truth is hard to talk about.
We’d like to talk about some tough news. Who would you like to include to make sure you’re supported?Breaking news We think that your body is dying, and we want to talk with you and your family about this. We think that we should shift our focus to supporting your comfort. This would look like focusing on your symptoms and helping you feel as good as possible, while also realizing that more testing won’t help us decide on a medical plan anymore.
Despite everything we’ve done, it appears your body is dying.Creating plans We want to create a plan of care that respects you. Based on our discussion, it sounds like you are thinking about the end of your life and dying.
We will shift to a focus of allowing your body to go through the natural dying process without trying to slow down or reverse this process.
Are there any important considerations before we shift our focus? For example, are there religious rituals we should arrange or family members or friends we should ask to visit?
How involved do you want to be in creating the medical plan going forward? We anticipate that over time we will both stop and start medications, depending on how they’re supporting your body.
One of your stated goals is eating for pleasure. We want to support this. In setting this goal, we also need to think about your breathing. We know the food has sometimes been going down into your lungs.
As you eat, we think it would be reasonable to adjust the nasal cannula as needed, but if you get to the point of needing a mask or breathing tube, we’d recommend against that.- TABLE 2
Considerations for a comfort care order set: Communication, regular care, and patient monitoring
Indication Order examples Considerations Communication Nursing communication Check on patient every 2 hours for signs of distress including grimacing or changes in mentation or breathing Change from traditional vital signs to monitoring patient for comfort during dying process
Clinicians should ask to be alerted for any uncontrolled symptoms despite appropriate medication administrationCode status Comfort care
Do not resuscitate or intubateEnsure patient, family, and nursing team are aware of plan
States may have additional nuanced code status options; clinicians should ensure they are familiar with those available to themRegular care and patient monitoring Room ambiance Open blinds and turn on lights during day; close blinds and turn lights off at night
Consider placing television to comforting music channel
Place comfort care cart at bedsideAll should be at patient or caregiver preference
Depending on hospital protocol, cart or sign may be placed outside door to indicate shift in care to staffPatient assistance Turn patient every 2 hours to maintain comfort
Assist patient with movement as appropriate
Assist patient with toileting as appropriateCustomize orders to patient condition and preference
Consider whether foley catheter or other toileting devices can aid in patient comfortWound care Reconsult wound care specialist for recommendations in setting of comfort care with goal of maximum comfort to wound Transitioning wound care to focus on comfort rather than healing may result in fewer bandage changes or changing materials used
Emphasize in communication that the body does not have the energy to heal, and care will be directed to minimizing pain or other discomfort, such as odor, from woundsPhysical and occupational therapy Provide recommendations for therapy with goal of maximum comfort Transition may include recommendations for passive movement to avoid contractures and pain, as well as massage
Encourage families to learn and be involved, as ableVital signs Discontinue vital sign monitoring
Monitor vital signs only on patient or family requestExplain to patient and family that care will be determined based on physical examination and patient symptoms rather than numerical data Oxygen use, titration Discontinue supplemental oxygen
Continue oxygen at current level, but do not increaseConsider stopping entirely, not titrating up, or setting a limit to titration
Coach families and staff around plans to use for symptoms rather than to meet an oxygen saturation goalOther monitoring Blood glucose: continue, change frequency, or discontinue blood glucose checks
Fluid status: discontinue or continue daily weights; allow patient to drink according to thirstPatients accustomed to close monitoring may require repeated discussions and stepwise changes in care Based on information from references 10–12.
Indication Order examples Considerations Devices and procedures Pacemaker Consider cardiology consultation if changing settings will provide comfort Pacemakers will discontinue pacing when the body dies; consider leaving activated for comfort Internal cardiac defibrillator (ICD) Please consult cardiology for deactivation of ICD in setting of goals of comfort care If emergent deactivation is required before cardiology is available, a specialized magnet can be placed externally to deactivate ICD Endotracheal tube (ETT) Consult respiratory therapy for extubation to comfort care
Extubate to face mask, nasal cannula, or room air depending on projected clinical trajectory and goalsConsider if family and friends would like to be present
Consider premedication for dyspnea and anxiety
Consider what level of oxygenation support will bring the patient comfort after removal of ETT, such as nasal cannula, face mask, or noninvasive ventilation supportMedications for symptom control (all as needed)ab Breakthrough pain or dyspnea Morphine concentrated liquid 5–15 mg orally or sublingually every 3–4 hours Can be used when patient loses ability to take oral medications Terminal fever or pain Acetaminophen 325–650 mg orally or rectally every 4–6 hours Pills can be used orally or rectally Nausea and vomiting Ondansetron 4–8 mg orally, sublingually, or intravenously every 8–12 hours
Promethazine 12.5–25 mg orally or rectally every 8 hours
Olanzapine 2.5–5 mg orally or sublingually every 12–24 hoursConsider whether single medications can be used for multiple symptoms, such as olanzapine for both nausea and agitation Constipation prevention Assess for daily bowel movement While bowel movements may slow, worsening constipation may add to agitation at end of life
Suppositories are recommended when patient loses ability to swallowAnxiety, terminal agitation Lorazepam 0.5–2 mg orally or intravenously every 6–8 hours
Haloperidol 0.5–5 mg orally, intravenously, or intramuscularly every 8–12 hours
Olanzapine 2.5–5 mg orally or sublingually every 12–24 hoursThese medications are useful for spectrum of symptoms in terminal phase Terminal secretions (“death rattle”) Atropine 1% 1–2 drops sublingually every 1–2 hours Coach family and nursing team on repositioning as well ↵aFor all initial medication dosing: if a patient has already been chronically on a medication, consider using the previously prescribed dose as an initial dose.
↵bConsider an approximately 50% dose reduction for all patients > 65 years or with severe renal or liver dysfunction.
Based on information from references 10–12.
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