Entering Comfort Care Orders: A Comprehensive Protocol
Comfort care orders should be implemented through an interprofessional care plan that includes specific provisions for symptom management, environmental modifications, family support, and discontinuation of non-comfort interventions. 1
Initial Steps for Comfort Care Implementation
- An interprofessional team including physician, nurse, and respiratory therapist should develop a comprehensive care plan before initiating comfort care orders 1
- Move the patient to a private room whenever possible, liberalize visitation policies, and turn off monitoring equipment to minimize distractions 1
- Use an unobtrusive signal (such as a sign on the door) to indicate comfort care is in progress to ensure a respectful atmosphere 1
- Enter orders through a validated computerized provider order entry system specifically designed for comfort care to ensure consistency 1
Required Components of Comfort Care Orders
- Clearly document the transition to "comfort measures only" status in the electronic health record 2
- Include specific medication orders for symptom management, particularly for:
- Specify the discontinuation of non-comfort interventions such as vital sign monitoring, laboratory tests, and non-essential medications 1
- Include orders for spiritual care consultation 4
- Document code status as "Do Not Attempt Resuscitation" if aligned with goals of care 1
Communication Requirements
- Document discussions with the patient (if capable) and/or family about the transition to comfort care 1
- Include orders for regular physician visits to the bedside to provide emotional and psychological support 1
- Establish clear communication channels between physicians and nurses regarding the patient's comfort level 1
- Document family preferences for presence during the dying process 1
Special Considerations
- For patients on mechanical ventilation, include specific orders for terminal extubation or terminal weaning based on patient/family preferences 1
- For patients with specific religious or cultural needs, document these requirements in the comfort care orders 1
- Include orders for bereavement support for family members after the patient's death 1
Common Pitfalls to Avoid
- Avoid the misconception that comfort care is only for the last hours to days of life; it can be beneficial for weeks to months 1, 5
- Do not automatically discontinue all treatments; instead, evaluate each intervention based on whether it contributes to comfort 5
- Avoid inadequate symptom management by ensuring appropriate medication dosing and frequent reassessment 1
- Do not neglect the importance of spiritual care, which is significantly more utilized when formal comfort care orders are in place 4
Follow-up Requirements
- Include orders for regular reassessment of symptoms and adjustment of medications as needed 3
- Document plans for debriefing sessions for the healthcare team, especially after difficult cases 1
- Include orders for follow-up with bereaved family members several weeks after the patient's death 1
By following this structured approach to entering comfort care orders, healthcare providers can ensure that patients receive appropriate end-of-life care that prioritizes comfort, dignity, and family support while avoiding unnecessary interventions that do not contribute to these goals 1.