ALL patients arrive at the Hospital/ICU with a FULL CODE status, this should be the default order on every patient. On occasion patients and families make the decision to change this code status, and a patient’s status in EPIC needs to be adjusted accordingly. An order needs to be placed if a patient is no longer a full code. The order to place is NOT “Comfort Care” but instead “Limited – No CPR”. This must be discussed with the fellow and attending. The surgical team should also be updated.

GOALS OF CARE ORDERS SHOULD NOT BE DISCUSSED WITH THE FAMILY OR PATIENT WITHOUT THE SICU/ SURGICAL ATTENDING INVOLVEMENT. Withdrawal of treatment and limitation of treatment orders require attending SICU or attending surgeon signatures within 24 hours. Specific forms are available to delineate these orders.

PALLIATIVE CARE

COMFORT CARE GUIDELINES

The following guidelines are one of many ways this process can be accomplished. There is a designated Comfort Care order set in Epic to assist you in the necessary orders for patients at the end of life. Please use the order set to ensure complete care. The ICU uses a lotus flower sign and places it on the door of dying patients so that all caregivers are aware of the patient’s comfort care trajectory. Please be mindful of conversations in the area of these rooms, as there are grieving families inside, and they deserve as much peace as we can provide in an ICU setting. Demonstrate empathy to the family by asking whether a chaplain is requested. Speaking to the charge nurse can facilitate delivery of a bereavement tray (snacks) for family and friends.

The goal of these guidelines is to assist the patient and family in the dying process so that death occurs comfortably for patients in whom the plan of treatment is now aimed at comfort and not cure. In providing end of life (EOL) care, the ethical principles of autonomy, beneficence, non-maleficence, and double effect are inherent. Based on the patient’s history, degree of organ system dysfunction, including requirements for ventilator, cardiovascular, and vasopressor support, consider the likely mechanism of death. This will help set the plan to ensure appropriate palliative EOL care.

  • Neuromuscular blockers have no role in palliative EOL care. Withhold neuromuscular blockers for a period sufficient to exclude residual discomfort. Note however, that in some patients with severe muscle weakness a residual NMB effect may be present. It is important to ensure that the patient receives adequate sedation in this situation. Consider ventilation with 100% oxygen to minimize the risk of air hunger while neuromuscular blockade effects diminish.
  • Based on discussions with the patient’s family and/or significant other, determine if they wish to be present during the period of transition of care from treatment to comfort, and what resources we can provide (chaplain, social worker, etc.)
  • Consider administration of glycopyrrolate to reduce secretions and “death rattle” if plan is to extubate.
  • Turn off or adjust bedside alarms/monitor.
  • Administer narcotics and benzodiazepines to eliminate pain, air hunger, and anxiety. It often helps to titrate medications to the set ventilator respiratory rate prior to extubation.

Opioid Narcotic Administration

It is preferable to administer opioids via continuous infusion in this situation. Bolus doses should be readily available at the bedside.

  • If patient is already receiving a narcotic and appears comfortable at a specific infusion rate, it is reasonable to give a bolus dose and then triple the rate. Titrate to the end points of achieving elimination of pain and air hunger and examination of pupils (pupils are often pinpoint with adequate opiates).
  • If patient is being managed with scheduled bolus administration of narcotics, administer repeated boluses at shorter intervals (e.g., every 5 minutes), and then begin an infusion with the previous hour’s amount. Increase until patient no longer responds to deep suctioning.
  • If no narcotics have been previously used, a bolus of morphine sulfate of 0.1 mg/kg or Fentanyl 3-5 mcg/kg can be administered intravenously and a morphine or fentanyl infusion can be initiated. Increase infusion until patient no longer responds to deep suctioning.

Benzodiazepine Administration

It is preferable to administer benzodiazepines via continuous infusion with extra bolus doses readily available at the bedside. If the patient is already receiving an IV infusion of an anxiolytic such as midazolam, it may be reasonable to give a bolus and then triple the infusion rate to ensure adequate depth. Titrate to the end points of achieving elimination of anxiety and air hunger. Benzodiazepines alone provide anxiolysis and amnesia with minimal effect on respiratory effort.

  • Confirm the patient has no apparent evidence of air hunger by reducing the FiO2 to 21%, and a machine rate of zero with PSV of 5 and PEEP of 5. If there is evidence of air hunger, resume ventilatory support and provide additional boluses of narcotics and anxiolytics and then repeat the reduction of ventilatory support.
  • When minimal or no evidence of air hunger is present, extubate the patient or maintain on IMV of 0 per ventilator with 21% or HHTC with 21%.
  • Be prepared to administer supplemental narcotics and anxiolytics. Remember the goal is comfort.
  • Once decision is made to change the goal of care to comfort, IVFs and vasopressors have no benefit for the patient. Discontinue other medications and mechanical support devices as appropriate. For example, discontinue medications such as vasopressors before discontinuation of mechanical ventilation.