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Comfort Care Measures Overview

Vital signs – prn to evaluate “End-of-Life Vital Signs” for comfort, heart rate
(tachycardia), respiration (apnea, rapid rate/tachypnea), temperature if warm to
touch, secretions (gurgling or coarse crackles).
Diet – Patient choice of time, quantity and type of food as tolerated. Family may
provide food.
Activity – as tolerated. Position of comfort.
Oxygen – 2 to 3 L/minute/nasal cannula prn shortness of breath (dyspnea).
Pain:
Optimal pain management is best achieved with routine or long-acting medication,
such as Morphine, Dilaudid, Oxycontin, Duragesic, etc. with a routine dosage
schedule.
Breakthrough pain, identified by verbalization, moaning, restlessness, grimacing,
etc, is treated with a short-acting oral medication, such as Roxanol or Dilaudid
liquid prn for breakthrough pain, shortness of breath, restlessness, agitation, cough.
Note: many residents are unable to ask for prn medications; observe for signs of
discomfort.
Anxiety, dyspnea, agitation or restlessness – Ativan Intensol 2 mg/ml – small
dose sublingual or oral, prn agitation, anxiety, shortness of breath (may be
beneficial on a regular basis for symptoms or to augment pain control).
Secretions – Scopolamine patch 1.5 mg – apply one to two patches q 72 hours prn
secretions, and/or Glycopyrrolate 1 mg po TID prn secretions, and/or Atropine 1%
ophthalmic 1 to 2 drops SL q 6 hours prn secretions.
Constipation (prevention is key) – DSS 100mg or 250mg 1 to 2 BID Plus Senna 1
to 2 po BID, or Sorbitol 30 ml po daily or BID prn constipation. If severe,
Lactulose 15 to 30 ml BID to TID.
Nausea – PRN orders for compazine or phenergan. Ativan prn helps nausea.
Agitation with psychosis, delirium – Haldol sublingual (SL) prn hallucination,
confusion, severe restlessness.
California POLST Education Program: Comfort Care Measures Overview March 2012 Coalition for Compassionate Care of California Materials made possible by a grant from the California HealthCare Foundation End-of-Life Vital Signs:
‰ “Routine vital signs” are usually discontinued when death is near and focus o Machinery to assess routine vital signs may cause patient or family o Information from routine vital signs, like respiratory rate and oxygen saturation, are usually not helpful and may cause confusion about treatments. ‰ “End-of-life vital signs” help assess comfort. o Heart rate (apical pulse with stethoscope or palpated radial pulse) to evaluate if tachycardia, often a sign of discomfort in the unconscious patient). o Respirations, looking at quality and character, such as irregular or apneic spells which show approaching death. ƒ Note: Opioids should not be held for slow, shallow respirations in the dying patient. o Secretions, wet respirations (gurgling, rattling, crackling) caused by pooling of oral secretions, can be treated. o Peripheral perfusion, inspecting/palpating extremities to evaluate mottling and cooling, which are signs that death is near. o Temperature, sweating and fever are common at the end of life and can be treated with acetaminophen, removal of blankets, fan, etc.
Key Points to “Honor Wishes for Comfort”:
‰ Relief of distressing symptoms and pain can improve comfort and quality of ‰ Medications are often required to relieve symptoms in the last days or hours ‰ Medications are to reduce pain and suffering, not to hasten death.
‰ The patient is dying from the medical illness, not the medications.
‰ Educating and supporting families can reduce suffering and distress during their loved one’s death and afterwards. California POLST Education Program: Comfort Care Measures Overview March 2012 Coalition for Compassionate Care of California Materials made possible by a grant from the California HealthCare Foundation

Source: http://med.fsu.edu/userFiles/file/Comfort%20Care%20Measures%20Overview.pdf