Domain 5 - Symptom Management & Comfort Care

  • Emphasize the comprehensive comfort care that will be provided to the patient rather than focus on the removal of life-sustaining treatments:
    • In initial clinical team meetings and subsequent discussions with the patient and/or family, enumerate interventions which can and will be provided to alleviate the patient's distressing symptoms, promote patient comfort, maintain patient dignity and maximize privacy for the patient and the family.
    • Inform the patient and/or family about the open visitation policy, availability of spiritual resources and cultural supports and how to access clinician liaison(s) if questions or concerns arise.
    • Create and institute a preprinted physician Comfort Care Order form.
    • Inquire about specific interventions, e.g., spiritual, physical, practical and emotional measures that would be comforting and meaningful to the dying patient and/or their family.
    • Include the above individualized comfort care measures on the preprinted physician Comfort Care Order form.
  • Institute and use uniform quantitative symptom assessment scales appropriate for communicative and non-communicative patients on a routine basis:
    • PAIN ASSESSMENT - a) communicative patients - consider using numerical rating scale(NRS), (0-10) or Baker Wong Faces scale; b) non-communicative patients - consider using a Behavioral Pain Assessment Scale(BPAS).
    • AGITATION ASSESSMENT - for both communicative and non-communicative patients - consider using either the Ramsey Scale, Riker Sedation-Agitation Scale(SAS), Motor Activity Assessment Scale(MAAS) or Vancouver Interaction and Calmness Scale(VIC).
    • DELIRIUM and CONFUSION - a) communicative patients - consider using either the Mini-Mental State Exam(MMSE) or Memorial Delirium Assessment Scale(MDAS); b) non-communicative patients - consider using either the Confusion Assessment Method for ICU (CAM-ICU), Delirium Rating Scale(DRS) or modified Memorial Delirium Assessment Scale(MMDAS).
    • Pain assessment section/category can be incorporated into preprinted and/or computerized ICU flowsheets, preprinted MD and RN ICU admission forms, preprinted MD and RN narrative notes and physician Comfort Care Order form.
  • Standardize and follow best clinical practices for symptom management:
    • SYMPTOM MANAGEMENT:
      • Prepare ICU policies establishing interdisciplinary accountability for symptom assessment and management.
      • Follow the Joint Commission for the Accreditation of Health Care Organizations' (JCAHO) 2001 Pain Management Standards and Intents.
      • Prepare clinician pain management guidelines which include:
        • Dosing for opioid naive and opioid tolerant patients;
        • Equianalgesic conversions;
        • Usefulness of round-the-clock dosing;
        • Recommended pharmacologic treatment of both nociceptive pain (including procedural pain) and neuropathic pain.
      • Modify flowsheets to include additional spaces for the assessment of pain intensity scores for multiple pain sites/locations, interventions and responses to interventions.
      • Develop preprinted ICU protocols and standing orders for the management of pain, agitation and delirium.
      • Educate family about terminal delirium as they may interpret the manifestations of agitated delirium as pain.
      • Palliate agitation and delirium aggressively as they may be particularly distressing to patients and families.
  • Use non-pharmacologic as well as pharmacologic measures to maximize comfort as appropriate and desired by the patient and family:
    • Optimize sleep patterns.
    • Maximize meaningful communication of patient with loved ones.
    • Re-orient patient frequently, if possible.
    • Move and turn as tolerated.
    • Reduce environmental stimuli and noise.
    • Incorporate individualized significant non-pharmacologic interventions into physician Comfort Care Order form.
  • Reassess and document symptoms following interventions:
    • Standardize and document reassessment after treatment.
  • Know and follow best clinical practices for withdrawing life-sustaining treatments to avoid patient and family distress:
    • Develop ICU protocol/guideline/pathway for the withdrawal of life-sustaining treatments, including standards for the withdrawal of ventilatory support in a manner to minimize discomfort.
    • Assess in advance the family's desire to have a pastoral care representative present when life-support is withdrawn from the patient.
    • Ensure the presence of the physician caring for the patient around the time life-support is withdrawn.
  • Eliminate unnecessary tests and procedures (lab work, weights, routine vital signs, etc.), and only maintain IVs for symptom management in situations where life-support is being withdrawn:
    • Develop protocol to ensure consistent implementation.
  • Minimize noxious stimuli (monitors, strong lights, etc.):
    • Develop protocol to ensure consistent implementation.
  • Attend to the patient's appearance and hygiene.
  • Ensure family and/or clinician presence so the patient is not dying alone:
    • Educate staff about the importance of their presence for the support of the patient and family.

Promoting Excellence in End-of-Life Care was a national program of the Robert Wood Johnson Foundation dedicated to long-term changes in health care institutions to substantially improve care for dying people and their families.