Download ICU Comfort Care: principles, guidelines, and goals

ICU Comfort Care guidelines. May 2008.
ICU Comfort Care guidelines
I. General Principles
1) All patients would like to be comfortable regardless of the goals of care.
Comfort care specifically refers to care which has as its primary goal the
promotion of comfort, not cure or life prolongation. It is aimed at improving quality
of life and it addresses the psychological, social, and spiritual needs of patients
and their families.
3) Comfort care in the ICU includes provision of treatments that promote comfort
and the withholding or withdrawal of treatments that are primarily intended to
cure or prolong life.
4) Comfort care provided in the ICU differs from palliative care provided outside
of the ICU in that ICU comfort care is typically delivered over a much shorter time
frame, often measured in minutes, hours, or in some cases a few days.
4) Death occurs as a complication of the underlying disease. The goal of
comfort care is to relieve suffering in a dying patient, not to hasten death. Actions
solely intended to hasten death (for example, high doses of potassium or
paralytic drugs) are morally unacceptable and illegal.
5) Withdrawal of life sustaining treatment is a medical procedure that requires
the same degree of physician participation and attention to quality as other
procedures.
6) Withdrawing treatments is morally and legally equivalent to withholding them,
although it may feel different for clinicians.
7) Any treatment can be withdrawn including artificial nutrition, fluids, antibiotics,
blood products, ventilator support, and vasopressors.
8) Assessing pain and discomfort in intubated critically ill patients or patients
with altered mental status can be difficult. When opioids or sedation are
increased the justification for the increase should be documented in the medical
record with particular attention to objective criteria such as tachypnea,
tachycardia, diaphoresis, grimacing, accessory muscle use, or moaning, nasal
flaring, and restlessness.
9) Concerns about hastening death by over-sedating patients or through the
administration of opioids are understandable. However, when judiciously and
properly titrated, the risk of hastening death is low. Concerns about hastening
death must be balanced with the obligation to relieve suffering and promote
comfort. Where questions arise as to the proper balance or to appropriate
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ICU Comfort Care guidelines. May 2008.
dosing, guidance should be obtained from more senior ICU staff or clinicians with
relevant expertise. It may also be appropriate to request a Palliative Care
consultation.
10) Paralytic drugs should not be given prior to discontinuation of life support, as
such drugs will mask signs of discomfort and might be interpreted as an
intentional effort to hasten death, which would be illegal.
II. Special Considerations
1.
Clarifying goals of care
Comfort care orders are intended for use in end of life care when a
decision has been made that the primary goal of care is promotion of comfort, not
cure or life prolongation.
Comfort care is an active treatment plan with an
obligation to provide medical care designed to relieve pain or discomfort and to
promote quality of life. The goals of comfort care are to optimize comfort and
dignity by providing care that is respectful, involves the patient and family, has
appropriate treatment for primary and secondary symptoms as desired by the
patient or surrogate decision-maker, manages pain aggressively, responds to
psychological, social, emotional and spiritual concerns of the patient and family,
sensitively addresses end of life issues such as autopsy and organ donation, and
is culturally relevant.
2.
Medication administration
When the primary goal of care has shifted from cure and life prolongation
to comfort, all interventions, especially medications, should be re-evaluated in
light of this new goal.
Consideration should be given to discontinuing
medications and interventions that do not contribute to comfort.
Other
medications may continue, where appropriate, in order to provide palliation of
symptoms and new medications may be considered in light of the change in
goals of care. Medications commonly administered include analgesics, including
opioids, which may also help with dyspnea, antipyretics, sedatives, and antiseizure medications.
3.
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Psychosocial and spiritual care
Physicians, nurses, and other team members may help patients and their
families by:
Liberalizing visiting hours
Educating the family as appropriate regarding changes in the patient’s
status, and coaching of family members as to how they can best assist
with care of the patient
Attending to and supporting the needs of the family
Offering to contact the patient’s own clergy or spiritual adviser
Calling upon social work, psychology and chaplaincy as needed for
additional support
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ICU Comfort Care guidelines. May 2008.
4.
Artificial hydration and nutrition
Fluid management should be individualized. IV access may help with
medication administration but in many situations may be discontinued. For most
patients close to death, artificial feeding is not thought to be beneficial either in
terms of life prolongation or the provision of comfort because hunger is generally
lost. In certain instances, parenteral fluids may be helpful particularly in treating
or ameliorating delirium. Fluids may also help some susceptible to nausea.
However, in most patients close to death thirst has disappeared. However, dry
mouth is frequently a significant problem for dying patients. There is not good
evidence that IV hydration helps with dry mouth. Skilled mouth care is most
helpful for dealing with dry mouth. IV hydration may be burdensome for some
patients, especially if it is difficult to maintain IV access. There is also a risk of
increasing GI and pulmonary secretions with hydration which may be problematic
for certain patients. Actively dying patients frequently have trouble handling
pulmonary secretions due to a decreased cough reflex.
III. Procedures
1. Determine that comfort care, including withholding and withdrawing life
sustaining treatment, is appropriate for the patient.
One of the following criteria (a – e) must be met:
a.
The patient has decision-making capacity and has been advised of the
consequences, risks, benefits, and alternatives and chooses comfort care,
including withholding and withdrawing life sustaining treatment, in the ICU.
b.
The patient does not have decision-making capacity, is not expected to
regain it and has an advance directive stating that he/she would not like to
remain on life-sustaining therapy in such a condition. Discussion with
family members/health care proxy is required.
c.
The patient does not have decision-making capacity, is not expected to
regain it and has a health care proxy who states that the patient would not
like to remain on life-sustaining therapy in such a condition.
d.
The patient does not have decision-making capacity, is not expected to
regain it, does not have a Health Care Proxy and the next-of-kin states
that the patient would not like to remain on life-sustaining therapy in such
a condition.
e.
The patient does not have decision-making capacity, is not expected to
regain it, and has no advance directive, Health Care Proxy or next-of-kin.
In this case, request a Clinical Bioethics Committee consultation and refer
to VA PALO ALTO HEALTH CARE SYSTEM MEMORANDUM No. 1105-04 SUBJ:WITHHOLDING AND WITHDRAWING OF LIFE SUPPORT
INCLUDING DO NOT RESUSCITATE ORDERS.
When there is more than one surrogate at the same priority level, consensus
about the decision to shift goals of care to comfort care, including withholding
and withdrawing life sustaining treatment, must be reached before it can be
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commenced. If surrogates cannot agree, a Clinical Bioethics Committee
consultation must be requested.
If there is any suspicion that the surrogate is not acting in the patient’s best
interest, withholding and withdrawal of life sustaining treatment must be
postponed until the treatment team involves the Clinical Bioethics Committee
and/or Regional Counsel.
The clinician should routinely explore goals of care for the patient with either the
patient, if decision making capacity is present or with the acknowledged proxy.
Goals of care should be re-evaluated periodically, based on the patient's clinical
course whenever a dramatic change in the patient's prognosis has occurred, and
whenever a request for reevaluation is made by the patient or proxy.
2. Expected procedures as part of withdrawal of life sustaining treatment,
including terminal wean/extubation
a.
Prepare staff. Discuss with all relevant staff your discussion your
rationale for what you would like to do and address any concerns they
might have about discontinuation or initiation of therapies and any ethical
or procedural concerns they might have.
b.
Prepare the patient/family/surrogate
i.
Ask patient or surrogates if they have any specific requests
regarding spiritual representatives or ceremonies. If they do,
arrange it either with the hospital chaplain or the preferred spiritual
representative. Sometimes the patient or surrogates wish to have
family and friends present for the process and sometimes they do
not.
ii.
Arrange for withdrawal of life sustaining treatment, including
terminal wean/extubation, at a time that is convenient for the
patient, family and friends.
iii.
Ask the patient’s family if they wish to be present for withdrawal of
life-sustaining treatment, including terminal wean/extubation.
They may choose to be absent during a wean/extubation but to
return to the room thereafter. If they choose to be present,
educate them as to what they may expect to see. Develop a plan
with the family to deal with any unforeseen events. For example, if
a patient started to seize or vomit, you might agree that you would
ask the family to leave until the situation is stabilized.
iv.
Inform the patient or surrogates of the likely outcomes of withdrawal
of life sustaining treatment, including terminal wean/extubation. For
example, inform them that some patients breathe easily while some
do not in the setting of a terminal wean/extubation. Some live for
days and some die within minutes. The treatment team cannot
predict what will happen. Review what can be done to keep
patients comfortable.
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ICU Comfort Care guidelines. May 2008.
v.
c.
d.
e.
f.
g.
h.
i.
Allow the family and friends to be part of the process. Encourage
them to touch and speak to the patient. Encourage them to notify
the staff if they perceive that the patient is in any discomfort.
vi.
Advise the family that if the patient stabilizes he or she may be
transferred out of the ICU to another unit.
Assure that the environment is comfortable for the patient and his/her
family and friends. This includes tissue boxes and chairs.
Offer to discontinue monitors. Some families may not desire this, but
most will welcome being able to make a choice.
Remove unnecessary tubes, lines, and drains.
Remove unused intravenous pumps, resuscitation carts, and other mobile
technology from the room.
Continue intravenous access for the administration of comfort
medications.
Discontinue all medications that are not indicated for comfort care, unless
previously agreed that they should be continued.
Discontinue all orders for laboratory and radiologic tests, unless they are
required for comfort care (usually not required).
3. Required procedures before shift to comfort care, including withholding
and withdrawal of life sustaining treatments
a.
Complete Comfort Care note that will include documentation of rationale
for comfort care and discussion with attending, patient, and/or
family/surrogate decision maker. For patient’s lacking decision making
capacity, the family member/surrogate decision maker must be named
and relationship noted within progress note
b.
Enter order for Do Not Resuscitate/Do Not Reintubate (DNR/DNI).
c.
Ensure medications to relieve pain, dyspnea and agitation are available
for immediate use as needed. Ensure the availability of medications to
relieve other distressing symptoms that the patient is experiencing.
d.
An attending physician or fellow and a respiratory therapist will be at the
bedside to wean/extubate patient receiving mechanical ventilation and
ensure that the patient remains comfortable.
e.
A member of the Palliative Care Team may be present, if requested.
IV. Resources
1. Curtis JR. Interventions to improve care during withdrawal of life-sustaining
treatments. J Palliat Medicine 2005; 8(S): 116-131.
2. Gavrin JR. Ethical considerations at the end of life in the intensive care unit.
Crit Care Med 2007; 35:S85-94.
3. Lanken PN, Terry PB, Delisser HM, Fahy BF, Hansen-Flaschen J, Heffner
JE, Levy M, Mularski RA, Osborne ML, Prendergast TJ, Rocker G, Sibbald
WJ, Wilfond B, Yankaskas JR; ATS End-of-Life Care Task Force. An official
American Thoracic Society Clinical Policy Statement: Palliatiave care for
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patients with respiratory diseases and critical illnesses. Am J Respir Crit Care
Med 2008; 177:912-927.
4. Lorenz KA, Lynn J, Dy SM, Shugarman LR, Wilkinson A, Mularski RA,
Morton SC, Hughes RG, Hilton LK, Maglione M, Rhodes SL, Rolon C, Sun
VC, Shekelle PG. Evidence for improving palliative care at the end of life: a
systematic review. Ann Intern Med 2008; 148:147-159.
5. Qaseem A, Snow V, Shekelle P, Casey DE Jr, Cross JT Jr, Owens DK;
Clinical Efficacy Assessment Subcommittee of the American College of
Physicians, Dallas P, Dolan NC, Forciea MA, Halasyamani L, Hopkins RH Jr,
Shekelle P.Evidence-based interventions to improve the palliative care of
pain, dyspnea, and depression at the end of life: a clinical practice guideline
from the American College of Physicians. Ann Intern Med 2008; 148:141-146.
6. Rubenfeld GD. Principles and practice of withdrawing life-sustaining
treatments. Crit Care Clin 2004; 20:435-451.
7. Sprung CL et al. Relieving suffering or intentionally hastening death: Where
do you draw the line? Crit Care Med 2008; 36:8-13.
8. Treece PD, Engelberg RA, Crowley L, Chan JD, Rubenfeld GD, Steinberg
KP, Curtis JR. Evaluation of a standardized order form for the withdrawal of
life support in the intensive care unit. Crit Care Med. 2004 May;32(5):1141-8.
9. Truog RD, Campbell ML, Curtis JR, Haas CE, Luce JM, Rubenfeld GD,
Rushton CH, Kaufman DC.. Recommendations for end-of-life care in the
intensive care unit: A consensus statement by the American Academy of
Critical Care Medicine. Crit Care Med 2008; 36:953-963.
10. von Gunten CF and Weissman DE. Ventilator Withdrawal Protocol. Fast Fact
and Concept #33, 34 and 35; 2nd Edition, July 2005. End-of-Life Palliative
Education Resource Center. http://www.eperc.mcw.edu/ff_index.htm.
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