What are the key components of a comfort review for patients requiring palliative care?

Key Components of a Comfort Review for Palliative Care Patients

A comprehensive comfort review for palliative patients should include systematic assessment and management of physical symptoms, psychosocial distress, spiritual needs, and advance care planning, with regular reassessment to optimize quality of life during the dying process. 1

Physical Symptom Assessment and Management

Pain Management

• Use validated assessment tools appropriate to patient's communication abilities (0-10 numeric rating scale for self-reporting patients) 2
• Implement a tiered approach to pain management:
  • Mild pain: Acetaminophen/paracetamol 1
  • Moderate to severe pain: Opioids (morphine as first-line) 1, 3
  • Neuropathic pain: Add anticonvulsants or antidepressants 1
  • Bone pain in cancer: Consider bisphosphonates 1

Respiratory Symptom Management

• Assess dyspnea using appropriate scales (0-10 numeric rating scale) 2
• Non-pharmacological interventions:
  • Positioning (sitting upright)
  • Hand-held fans directed at face
  • Relaxation techniques and breathing exercises 1
• Pharmacological management:
  • Morphine 2.5-10 mg PO q2h PRN or 1-3 mg IV q2h PRN 1, 3
  • Monitor for respiratory depression, especially within first 24-72 hours 3

Gastrointestinal Symptom Management

• Assess for constipation, nausea/vomiting, anorexia/cachexia 1
• Constipation management:
  • Increase fluids and dietary fiber
  • Laxatives, stool softeners
  • Methylnaltrexone for opioid-induced constipation 1
• Nausea/vomiting management:
  • Metoclopramide, 5-HT3 antagonists, promethazine, prochlorperazine 1
• Thirst management:
  • Frequent mouth care
  • Ice chips or small sips of fluid 2

Neuropsychiatric Symptom Management

• Assess for delirium, insomnia, sedation, anxiety 1
• Delirium management:
  • Reduce or eliminate delirium-inducing medications (steroids, anticholinergics) 1
  • Consider low-dose antipsychotics for symptomatic management
• Insomnia/anxiety management:
  • Address underlying causes
  • Consider non-pharmacological approaches first
  • Use appropriate sedatives when necessary 2

Psychosocial and Spiritual Assessment

• Evaluate psychological distress using standardized tools 1
• Assess for:
  • Depression and anxiety
  • Feelings of helplessness/hopelessness
  • Existential distress 2
• Consider psychiatric/psychology referral for moderate-severe psychological distress 1
• Spiritual assessment using tools like FICA (Faith and Belief, Importance, Community, Address in Care) 1
• Address cultural factors affecting care preferences 1

Environmental Comfort

• Create a safe, aesthetic, and pleasing environment 1
• Reduce excessive stimuli
• Ensure comfortable room temperature
• Provide privacy and respectful space for family interactions 2
• Regular repositioning for physical comfort 2
• Monitor for urinary retention and fecal impaction 2

Family Support and Communication

• Establish rapport with family members
• Identify spokesperson if appropriate
• Provide regular counseling and psychosocial support
• Address anticipatory grief 1
• Educate family about the dying process 2
• Explain normal changes in appetite and thirst during dying process 1

Advance Care Planning

• Discuss goals of care and treatment preferences
• Complete advance directives
• Determine preferred place of death 1
• Honor patient's wishes regarding care 2
• Discuss when to transition to comfort measures only 2

Refractory Symptom Management

• For intractable symptoms despite optimal palliative care:
  • Consider palliative sedation for patients with terminal illness and life expectancy of a few weeks or less 2
  • Typical sedatives: pentobarbital, thiopental, midazolam 2
  • Include planned periods of medication withdrawal for reassessment 2
  • Apply the doctrine of double effect (intent is symptom relief, not hastening death) 2

Regular Reassessment

• Establish frequency of follow-up based on symptom burden
• Provide 24/7 contact information for support
• Schedule team meetings to review care plan and adjust as needed 1
• Reassess for the five key outcomes:
  1. Adequate pain and symptom management
  2. Reduction of patient/family distress
  3. Acceptable sense of control
  4. Relief of caregiver burden
  5. Optimized quality of life 2

Common Pitfalls to Avoid

• Delaying palliative care integration until final days of life 1
• Focusing solely on pharmacological interventions without implementing non-pharmacological strategies 1
• Neglecting psychosocial and spiritual needs of patient and family 1
• Failing to complete advance care planning early in disease course 1
• Avoiding opioids due to addiction concerns when they are essential for symptom control 1, 3
• Continuing medications that may cause harm (e.g., NSAIDs with thrombocytopenia) 1

By systematically addressing these components in a comfort review, healthcare providers can optimize quality of life for palliative care patients while minimizing suffering and supporting both patients and their families through the dying process.