ICU Cornestone: a lecture that changed my practice

Impact of writing "comfort measures only" orders in a community teaching hospital

OBJECTIVES

We compared end-of-life care for patients with and without orders for "comfort measures only" (CMO) and evaluated whether standards for palliative medicine were met.

DESIGN

We retrospectively reviewed the charts of 40 patients, 20 with and 20 without a CMO order, who died in our community teaching hospital from October 2003 through September 2004. Appropriate use of medications and interventions and documentation of symptoms and family consultation were examined.

RESULTS

There were no significant demographic differences between the groups. Family meeting (18/20 versus 7/20, p < 0.001) and do-not-resuscitate/do-not-intubate (DNR/DNI) code status (20/20 versus 8/20; p < 0.001) occurred significantly more frequently in the CMO group. There were no other significant differences in prescribing medications or treatments. Notation of symptoms common at the end of life did not differ between the groups except for nausea/vomiting, which was more common in the non-CMO group. In the CMO group, opioids were significantly more available and antibiotics and routine laboratory work were significantly less common after the CMO order, but no other differences were observed.

CONCLUSION

CMO orders alone were insufficient for redirecting changes in care at the end-of-life.

Assessment of implementation of an order protocol for end-of-life symptom management

OBJECTIVES

Designing comfort care plans to treat symptoms at the end-of-life in the hospital is challenging. We evaluated the implementation of an inpatient end-of-life symptom management order (ESMO) protocol that guides the use of opiate medications and other modalities to provide palliation.

METHODS

Physicians and nurses caring for patients using the ESMO protocol were surveyed about care provided and their experiences.

RESULTS

Over 342 days, 127 patients (2.6 per week) were treated using the ESMO protocol and we surveyed a nurse and/or physician for 105 (83%) patients. Most patients were comatose, obtunded/stuperous, or disoriented when the ESMO protocol was initiated and most had a life expectancy of less than 1 day. One fourth of physicians felt that the protocol was instituted too late, principally citing family unwillingness to reorient toward comfort care. Providers reported that opiates were titrated appropriately, although a minority revealed discomfort with end-of-life opiate use. Nearly all clinicians found the ESMO protocol to be valuable.

CONCLUSIONS

A standardized protocol is a useful, but not fully sufficient, step toward improving care for dying hospitalized patients.

End-of-life care in UK critical care units--a literature review

AIM

To appraise literature concerning end-of-life care (ELC) in adult critical care units in the UK in order to improve clinical practice.

OBJECTIVE

To understand the interplay between legal and ethical, political, societal aspects of ELC for sustainable quality care.

BACKGROUND

Significant changes in health care policy for the critically ill patient have occurred since 1999. Simultaneously, the government is committed to improving care for the dying by integrating the palliative care ethos across the National Institutes of Health (NHS) to include non-cancer sufferers. Death continues to be a feature of critical illness, particularly following the decision to withhold/withdraw life-prolonging treatments.

SEARCH STRATEGY

A search of MEDLINE, BNI, CINAHL and PSYCinfo using key words revealed very few results; consequently, the search was broadened to include ASSIA, King's Fund, TRIP, Healthstar, NHS Economic Evaluation Data, Cochrane, professional journals and government documents.

CONCLUSIONS

The literature reveals a paradigm shift from critical to palliative care, in other words, from a reductionist approach to a more humanistic approach in the acute setting. When treatment is deemed futile, quality ELC involving the assessment, ongoing assessment and care after death becomes the new goal for the critical care team. To practice ELC competently, nurses require organizational and educational support at local and national levels.

RELEVANCE TO CLINICAL PRACTICE

Although medico-legal decision-making is not part of their professional role, critical care nurses have an extraordinary opportunity to make a difference to the dying patient and their family and their acceptance of death.