Comfort measures: practical care of the dying cancer patient

Effectiveness and safety of implementing an enhanced patient comfort programme for elective neurosurgical patients: a randomised controlled trial protocol

INTRODUCTION

Patient comfort is an important quality indicator of healthcare. According to Kolcaba's comfort theory, enhanced comfort is achieved by meeting the needs in four contexts: physical, psychospiritual, sociocultural and environmental. An enhanced patient comfort (EPC) programme based on this theory has been designed for elective neurosurgical patients. This study aims to assess its feasibility, effectiveness and safety.

METHODS AND ANALYSIS

The EPC programme patients will be evaluated in a single institutional randomised controlled trial. A total of 110 patients admitted for elective neurosurgery (including craniotomy, endoscopic trans-sphenoidal surgery and spine surgery) will be randomised in a 1:1 ratio to two groups. Patients in the EPC group are managed under the newly developed EPC programme, which aims to enhance patient experience and includes care coordination since admission (such as appointment of a care support coordinator, personalised setting, and cultural and spiritual support), preoperative management (such as lifestyle intervention, potential psychological and sleep intervention, and prerehabilitation), intraoperative and anaesthetic management (such as nurse coaching, music playing, and pre-emptive warming), postoperative management (such as early extubation, early diet advancement, mood and sleep management, and early ambulation) and optimised discharge planning; while those in the control group receive conventional perioperative care. The primary outcome is patient satisfaction and comfort measured by the Chinese Surgical Inpatient Satisfaction and Comfort Questionnaire. The secondary outcomes include postoperative morbidity and mortality, postoperative pain score, postoperative nausea and vomiting, functional recovery status (Karnofsky performance status and Quality of Recovery-15 score), mental status (anxiety and depression), nutritional status, health-related quality of life, hospital length of stay, reoperation and readmission rates, overall cost and patient experience.

ETHICS AND DISSEMINATION

Ethical approval to conduct the study has been obtained from Institutional Review Board of Xi'an International Medical Center (No. 202028). The results will be presented at scientific meetings and published in peer-reviewed journals.

TRIAL REGISTRATION NUMBER

Chinese clinical trial registry ChiCTR2000039983.

Battling a Tangled Web: The Lived Experience of Nurses Providing End-of-Life Care on an Acute Medical Unit

Meeting the heath care needs of patients at the end of life is becoming more complex. In Canada, most patients with life-limiting illness will die in hospitals, many on medical units. Yet, few studies have qualitatively investigated end-of-life care (EOLC) in this context, or from the perspectives of nurses providing EOLC. The purpose of this study was to seek to understand the lived experience of nurses on a medical unit providing EOLC to patients. Interpretive phenomenology guided the method and analysis. Individual face-to-face interviews were conducted with 10 nurses from 2 hospital medical units. The underlying essence of these nurses' experiences was that of "battling a tangled web." Battling a tangled web represented their struggles in attempting to provide EOLC in an environment that was not always conducive to it. Seven themes were generated from the analysis: caring in complexity, caught in a tangled web, bearing witness to suffering, weaving a way to get there: struggling through the process, creating comfort for the patient, working through the dying process with the family, and finding a way through the web. The findings contribute to an understanding of the experiences of nurses in providing EOLC on a medical unit including perceived facilitators and barriers.

Comfort experience in palliative care: a phenomenological study

Background

Palliative care aims to provide maximum comfort to the patient. However it is unknown what factors facilitate or hinder the experience of comfort, from the perspective of inpatients of palliative care units. This lack of knowledge hinders the development of comfort interventions adjusted to these patients. The aim of this research is to describe the comfort and discomfort experienced by inpatients at palliative care units.

Methods

A phenomenological descriptive study was undertaken. Ten inpatients were recruited from a Spanish palliative care unit and seven from a Portuguese palliative care unit. Data were collected using individual interviews and analysed following the method of Giorgi.

Results

Four themes reflect the essence of the lived experience: The Palliative Care as a response to the patient’s needs with advanced disease, attempt to naturalize advanced disease, confrontation with their own vulnerability, openness to the spiritual dimension.

Conclusions

Informants revealed that they experience comfort through humanized care, differentiated environment, symptomatic control, hope and relationships. The discomfort emerges from the losses and powerlessness against their situation. Even if such findings may seem intuitive, documenting them is essential because it invites us to reflect on our convictions about what it means to be comfortable for these patients, and allows incorporating this information in the design of focused interventions to maximize the comfort experience.

Electronic supplementary material

The online version of this article (doi:10.1186/s12904-016-0145-0) contains supplementary material, which is available to authorized users.

Comfort measures: a concept analysis

Reference to the concept of comfort measures is growing in the nursing and medical literature; however, the concept of comfort measures is rarely defined. For the comfort work of nurses to be recognized, nurses must be able to identify and delineate the key attributes of comfort measures. A concept analysis using Rodgers' evolutionary method (2000) was undertaken with the goal of identifying the core attributes of comfort measures and thereby clarifying this concept. Health care literature was accessed from the CINAHL and PubMed databases. No restrictions were placed on publication dates. Four main themes of attributes for comfort measures were identified during the analysis. Comfort measures involve an active, strategic process including elements of "stepping in" and "stepping back," are both simple and complex, move from a physical to a holistic perspective and are a part of supportive care. The antecedents to comfort measures are comfort needs and the most common consequence of comfort measures is enhanced comfort. Although the concept of comfort measures is often associated with end-of-life care, this analysis suggests that comfort measures are appropriate for nursing care in all settings and should be increasingly considered in the clinical management of patients who are living with multiple, chronic comorbidities.

The consistency between treatments provided to nursing facility residents and orders on the physician orders for life-sustaining treatment form

OBJECTIVES

To evaluate the consistency between treatments provided and Physician Orders for Life-Sustaining Treatment (POLST) orders.

DESIGN

Retrospective chart abstraction.

SETTING

Stratified, random sample of 90 nursing facilities in Oregon, Wisconsin, and West Virginia.

PARTICIPANTS

Eight hundred seventy living and deceased nursing facility residents aged 65 and older with a minimum 60-day stay.

MEASUREMENTS

Chart data about POLST form orders and related treatments over a 60-day period were abstracted. Decision rules were created to determine whether the rationale for each treatment was consistent with POLST orders.

RESULTS

Most residents (85.2%) had the same POLST form in place during the review period. A majority of treatments provided to residents with orders for comfort measures only (74.3%) and limited antibiotics (83.3%) were consistent with POLST orders because they were primarily comfort focused rather than life-prolonging, but antibiotics were provided to 32.1% of residents with orders for no antibiotics. Overall consistency rates between treatments and POLST orders were high for resuscitation (98%), medical interventions (91.1%), and antibiotics (92.9%) and modest for feeding tubes (63.6%). In all, POLST orders were consistent with treatments provided 94.0% of the time.

CONCLUSION

With the exception of feeding tubes and antibiotic use in residents with orders for no antibiotics, the use of medical treatments was nearly always consistent with POLST orders to provide or withhold life-sustaining interventions. The POLST program is a useful tool for ensuring that the treatment preferences of nursing facility residents are honored.