From the Guidelines
A comfort care order set for a patient with intraparenchymal hemorrhage should prioritize symptom management and dignity, focusing on medications and interventions that alleviate pain, respiratory distress, and agitation, while avoiding unnecessary and burdensome treatments. The key components of such an order set include medications for pain control, such as morphine 2-4mg IV every 1-2 hours as needed or a continuous infusion at 1-4mg/hour, or hydromorphone 0.5-1mg IV every 1-2 hours as needed 1. For respiratory distress, morphine as above or lorazepam 0.5-2mg IV every 4-6 hours can be used. Terminal secretions can be managed with glycopyrrolate 0.2-0.4mg IV/SC every 4-6 hours or scopolamine 0.4-0.6mg SC every 4-6 hours or transdermal patch 1.5mg every 72 hours. Agitation can be addressed with haloperidol 0.5-2mg IV/SC every 4-6 hours or midazolam 1-5mg IV/SC every 1-4 hours as needed.
Key Considerations
- Discontinuation of non-comfort interventions like neurological monitoring, blood draws, and IV fluids unless for medication administration is crucial in prioritizing the patient's comfort and dignity.
- Oral care, repositioning every 2 hours, and family support are essential nursing interventions that should be included in the comfort care order set.
- The medications used in the comfort care order set work by managing specific symptoms: opioids for pain and dyspnea by binding to opioid receptors, benzodiazepines for anxiety by enhancing GABA effects, anticholinergics for secretions by blocking acetylcholine, and antipsychotics for agitation by blocking dopamine receptors.
Evidence-Based Approach
The approach to comfort care in patients with intraparenchymal hemorrhage is guided by the principles of palliative care, which emphasizes the relief of suffering and improvement of quality of life 1. While there is limited specific guidance on comfort care order sets for intraparenchymal hemorrhage, the available evidence supports the use of medications and interventions that prioritize symptom management and patient dignity. The most recent and highest quality study, the 2022 guideline for the management of patients with spontaneous intracerebral hemorrhage, highlights the importance of individualized care and decision-making in the context of intraparenchymal hemorrhage 1.
Symptom Management
- Pain control: morphine 2-4mg IV every 1-2 hours as needed or a continuous infusion at 1-4mg/hour, or hydromorphone 0.5-1mg IV every 1-2 hours as needed.
- Respiratory distress: morphine as above or lorazepam 0.5-2mg IV every 4-6 hours.
- Terminal secretions: glycopyrrolate 0.2-0.4mg IV/SC every 4-6 hours or scopolamine 0.4-0.6mg SC every 4-6 hours or transdermal patch 1.5mg every 72 hours.
- Agitation: haloperidol 0.5-2mg IV/SC every 4-6 hours or midazolam 1-5mg IV/SC every 1-4 hours as needed.
From the Research
Key Components of Comfort Care Order Set
The key components of a comfort care order set for a patient with intraparenchymal hemorrhage include:
- Symptom management, such as diligent titration of medications and thoughtful ordering in de-escalation of life-support modalities 2
- Prognostication in the dying process to guide treatment planning and stewarding families 2
- Compassionate extubation, which necessitates anticipation of postextubation dyspnea or airway loss, and therefore may require step-wise weaning of pulmonary support 2
- General supportive measures, such as use of dark towels to camouflage blood loss, use of suction, and applying external pressure 3
- Use of sedative medication, with drugs recommended including diazepam, midazolam, diamorphine, and ketamine at varying doses and routes of administration 3
Considerations for Intraparenchymal Hemorrhage
Intraparenchymal hemorrhage is a serious condition with high morbidity and mortality, and comfort care order sets should take into account the specific needs of these patients, including:
- Rapid identification and management of the hemorrhage 4
- Blood pressure control, reversal of associated coagulopathy, and care in a dedicated stroke unit 4
- Surgical management of hydrocephalus and space occupying hemorrhage in the posterior fossa, as well as minimally invasive surgical management of primary, supratentorial intraparenchymal hemorrhage 4
- Realistic prognostic assessment to inform treatment decisions regarding intracerebral hemorrhage 5
End of Life Outcomes
Patients with intraparenchymal hemorrhage who are placed on comfort care order sets often have poor outcomes, with a high percentage dying in the hospital 6