Download the related podcast about Death in the ICU! When physicians have decided there is nothing more they can do for a patient, they will often speak with the families and encourage them to withdraw care. Our facility actually says “Comfort Measures Only (CMO)” instead of “Withdrawing Care” because withdrawing care implies that we will […]
Download the related podcast about Death in the ICU! When physicians have decided there is nothing more they can do for a patient, they will often speak with the families and encourage them to withdraw care. Our facility actually says “Comfort Measures Only (CMO)” instead of “Withdrawing Care” because withdrawing care implies that we will no longer take care of the patient and this is not true- we do everything we can to make our patients comfortable, free from pain, and free of anxiety. I have recently taken care of two patients that were made CMO and there are some things that I have learned that I can share. First, the decision is made by a group- physicians, the patient, family members, and possibly clergy. Some experienced nurses may feel comfortable gently broaching the subject with the family. This is obviously going to be dependent upon how comfortable the nurse feels about the situation and the nurse’s relationship with the family. Second, comfort measures only usually means turning off all vasoactive drips and taking patients off the ventilator. At our facility, there is policy that dictates what we document and how often we assess our patients. All alarms get turned off and we only monitor heart rate and O2 saturations. If I recall correctly, only one full assessment is made per shift. It is always important to obtain a copy of your hospital policy so you know exactly how to proceed. It is also important to obtain DNR (Do Not Resuscitate) status for the patient. // // If you are the RN who is actually transitioning from full care to CMO, it is important to set up your pain and/or anxiety medication before you remove your patient from the ventilator or turn off drips. My facility has preprinted orders for CMO and usually patients are placed on continuous drips of morphine and ativan. Physician orders dictate maximum rates of these drugs and often physicians write for boluses of morphine in addition to the continuous rate. There is an ethical issue at hand here for some nurses but many nurses I have talked with understand that these maximum doses are not killing the patient. This is illegal. CMO preprinted orders were designed to provide for maximum patient comfort without crossing the line with lethal doses. // // With your comfort drugs already running, the patient is extubated, life prolonging drips are turned off, and the titration of the pain and anxiety medication for comfort begins. Family members are often packed tight into the rooms, the lights can be turned off and as a courtesy, the doors are shut or curtains drawn for privacy. Our ICU rooms are always single rooms and occasionally, if a patient does not expire within a certain time frame, they can be transferred to another private room on a hospital floor. Families will often have a lot of questions and they want to know exactly what to expect. This is the most difficult part because there are no answers. I’ve been told that patients may either die within minutes or continue to have vital signs for days. My first CMO patient was extubated and he died 20 minutes later. He sounded like he was sleeping with loud snores and then he stopped breathing and his heart went into asystole. My second patient was much the same although she had been made CMO earlier in the day and when I came on the night shift, she died 3 hours later. Her HR had been very tachycardic and suddenly she dropped down to the 50’s. Basically her body was working to compensate by pumping faster and then she ran out of energy. It wasn’t very long after that that she died. In both situations, my patients were free from any type of distress. I have, however, heard stories from nurses that have had more traumatizing situations where dying patients have actually been gasping for air. This is why it is imperative to have your comfort medications in place with a full understanding of your max dose and bolus amounts and schedules.
Download the related podcast about Death in the ICU!
When physicians have decided there is nothing more they can do for a patient, they will often speak with the families and encourage them to withdraw care. Our facility actually says “Comfort Measures Only (CMO)” instead of “Withdrawing Care” because withdrawing care implies that we will no longer take care of the patient and this is not true- we do everything we can to make our patients comfortable, free from pain, and free of anxiety.
I have recently taken care of two patients that were made CMO and there are some things that I have learned that I can share. First, the decision is made by a group- physicians, the patient, family members, and possibly clergy. Some experienced nurses may feel comfortable gently broaching the subject with the family. This is obviously going to be dependent upon how comfortable the nurse feels about the situation and the nurse’s relationship with the family.
Second, comfort measures only usually means turning off all vasoactive drips and taking patients off the ventilator. At our facility, there is policy that dictates what we document and how often we assess our patients. All alarms get turned off and we only monitor heart rate and O2 saturations. If I recall correctly, only one full assessment is made per shift. It is always important to obtain a copy of your hospital policy so you know exactly how to proceed. It is also important to obtain DNR (Do Not Resuscitate) status for the patient.
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If you are the RN who is actually transitioning from full care to CMO, it is important to set up your pain and/or anxiety medication before you remove your patient from the ventilator or turn off drips. My facility has preprinted orders for CMO and usually patients are placed on continuous drips of morphine and ativan. Physician orders dictate maximum rates of these drugs and often physicians write for boluses of morphine in addition to the continuous rate. There is an ethical issue at hand here for some nurses but many nurses I have talked with understand that these maximum doses are not killing the patient. This is illegal. CMO preprinted orders were designed to provide for maximum patient comfort without crossing the line with lethal doses.
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With your comfort drugs already running, the patient is extubated, life prolonging drips are turned off, and the titration of the pain and anxiety medication for comfort begins. Family members are often packed tight into the rooms, the lights can be turned off and as a courtesy, the doors are shut or curtains drawn for privacy. Our ICU rooms are always single rooms and occasionally, if a patient does not expire within a certain time frame, they can be transferred to another private room on a hospital floor. Families will often have a lot of questions and they want to know exactly what to expect. This is the most difficult part because there are no answers. I’ve been told that patients may either die within minutes or continue to have vital signs for days.
My first CMO patient was extubated and he died 20 minutes later. He sounded like he was sleeping with loud snores and then he stopped breathing and his heart went into asystole. My second patient was much the same although she had been made CMO earlier in the day and when I came on the night shift, she died 3 hours later. Her HR had been very tachycardic and suddenly she dropped down to the 50’s. Basically her body was working to compensate by pumping faster and then she ran out of energy. It wasn’t very long after that that she died. In both situations, my patients were free from any type of distress. I have, however, heard stories from nurses that have had more traumatizing situations where dying patients have actually been gasping for air. This is why it is imperative to have your comfort medications in place with a full understanding of your max dose and bolus amounts and schedules.
There is something that nurses refer to as “the final turn.” This is when your dying patient is turned (our hospital has a two hour turning policy to prevent bedsores for all patients, even CMO patients) and death occurs shortly thereafter because the body is not able to compensate for the change in position. Anytime you are performing a bath or turning your patient, ask the family to stay close because it may not be long after any type of change in position that your patient’s heart rate drops.
A few other things…you may want to remind your colleagues that your patient is dying so as a courtesy to the family you can keep the hallways quiet or free from loud voices and laughter. Offer the family the assistance of the chaplain either during the dying process or after death has occurred. Allow the family to stay with the patient after death for as long as they would like (if your bedboard allows). Try to explain what will happen after the death BEFORE the patient dies as emotions usually erupt after the process has completed itself. Our facility requires very little from the families- we only ask the family to provide the name of a funeral home if they have one in mind. If not, the body is taken to the morgue and they can let us know later where they would like the body transferred.
Post mortem care is according to policy. Consult your policy before you remove patient lines (central lines, IV’s, foley catheter, etc.) because sometimes when an autopsy is going to be done, everything needs to be left in. Usually the patient is cleaned and zipped into a body bag with proper identification before transport to the morgue.
If the patient is going to be an organ donor, the situation changes. Donors are usually 1:1 patients (1 nurse for 1 patient) and they are kept hemodynamically stable until after organ procurement. The actual death occurs in the operating room.
I hope this is not too morbid of a post. The families of the patients that I have seen die in the ICU have been very appreciative of the opportunity and the support of the nursing and physician staff during the difficult decision making and the actual death process. They are able to say their goodbyes and obtain closure. And as a nurse, you get to be a big part of that!