Promoting Excellence : Seven End-of-Life Care Domains : Domain 5 – Symptom Management & Comfort Care

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Emphasize the comprehensive comfort care that will be provided to the patient rather than focus on the removal of life-sustaining treatments:

• In initial clinical team meetings and subsequent discussions with the patient and/or family, enumerate interventions which can and will be provided to alleviate the patient’s distressing symptoms, promote patient comfort, maintain patient dignity and maximize privacy for the patient and the family.
• Inform the patient and/or family about the open visitation policy, availability of spiritual resources and cultural supports and how to access clinician liaison(s) if questions or concerns arise.
• Create and institute a preprinted physician Comfort Care Order form.
• Inquire about specific interventions, e.g., spiritual, physical, practical and emotional measures that would be comforting and meaningful to the dying patient and/or their family.
• Include the above individualized comfort care measures on the preprinted physician Comfort Care Order form.

Institute and use uniform quantitative symptom assessment scales appropriate for communicative and non-communicative patients on a routine basis:

• PAIN ASSESSMENT – a) communicative patients – consider using numerical rating scale(NRS), (0-10) or Baker Wong Faces scale; b) non-communicative patients – consider using a Behavioral Pain Assessment Scale(BPAS).
• AGITATION ASSESSMENT – for both communicative and non-communicative patients – consider using either the Ramsey Scale, Riker Sedation-Agitation Scale(SAS), Motor Activity Assessment Scale(MAAS) or Vancouver Interaction and Calmness Scale(VIC).
• DELIRIUM and CONFUSION – a) communicative patients – consider using either the Mini-Mental State Exam(MMSE) or Memorial Delirium Assessment Scale(MDAS); b) non-communicative patients – consider using either the Confusion Assessment Method for ICU (CAM-ICU), Delirium Rating Scale(DRS) or modified Memorial Delirium Assessment Scale(MMDAS).
• Pain assessment section/category can be incorporated into preprinted and/or computerized ICU flowsheets, preprinted MD and RN ICU admission forms, preprinted MD and RN narrative notes and physician Comfort Care Order form.

Standardize and follow best clinical practices for symptom management:

• SYMPTOM MANAGEMENT:
  • Prepare ICU policies establishing interdisciplinary accountability for symptom assessment and management.
  • Follow the Joint Commission for the Accreditation of Health Care Organizations’ (JCAHO) 2001 Pain Management Standards and Intents.
  • Prepare clinician pain management guidelines which include:
    • Dosing for opioid naive and opioid tolerant patients;
    • Equianalgesic conversions;
    • Usefulness of round-the-clock dosing;
    • Recommended pharmacologic treatment of both nociceptive pain (including procedural pain) and neuropathic pain.
  • Modify flowsheets to include additional spaces for the assessment of pain intensity scores for multiple pain sites/locations, interventions and responses to interventions.
  • Develop preprinted ICU protocols and standing orders for the management of pain, agitation and delirium.
  • Educate family about terminal delirium as they may interpret the manifestations of agitated delirium as pain.
  • Palliate agitation and delirium aggressively as they may be particularly distressing to patients and families.

Use non-pharmacologic as well as pharmacologic measures to maximize comfort as appropriate and desired by the patient and family:

• Optimize sleep patterns.
• Maximize meaningful communication of patient with loved ones.
• Re-orient patient frequently, if possible.
• Move and turn as tolerated.
• Reduce environmental stimuli and noise.
• Incorporate individualized significant non-pharmacologic interventions into physician Comfort Care Order form.

Reassess and document symptoms following interventions:

• Standardize and document reassessment after treatment.

Know and follow best clinical practices for withdrawing life-sustaining treatments to avoid patient and family distress:

• Develop ICU protocol/guideline/pathway for the withdrawal of life-sustaining treatments, including standards for the withdrawal of ventilatory support in a manner to minimize discomfort.
• Assess in advance the family’s desire to have a pastoral care representative present when life-support is withdrawn from the patient.
• Ensure the presence of the physician caring for the patient around the time life-support is withdrawn.

Eliminate unnecessary tests and procedures (lab work, weights, routine vital signs, etc.), and only maintain IVs for symptom management in situations where life-support is being withdrawn:

• Develop protocol to ensure consistent implementation.

Minimize noxious stimuli (monitors, strong lights, etc.):

• Develop protocol to ensure consistent implementation.

Attend to the patient’s appearance and hygiene.

Ensure family and/or clinician presence so the patient is not dying alone:

• Educate staff about the importance of their presence for the support of the patient and family.
  

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Promoting Excellence in End-of-Life Care is a national program of The Robert Wood Johnson Foundation dedicated to long-term changes in health care institutions to substantially improve care for dying persons and their families. Visit PromotingExcellence.org for more resources.