The Comfort Measures Order Set at a Tertiary Care Academic Hospital: Is There a Comparable Difference in End-of-Life Care Between Patients Dying in Acute Care When CMOS Is Utilized?

Lau, Christine L.; Stilos, Kalli; Nowell, Allyson; Lau, Fanchea; Moore, Jennifer; Wynnychuk, Lesia

doi:10.1177/1049909117734228

Cited by 17 publications

(17 citation statements)

References 31 publications

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“…From a review of concerns with the Liverpool Care Pathway, the following priorities were determined for caring for dying patients: emphasizing individualized care and clinical judgment over universal checklists and educating clinicians on symptom management, communication skills, empathy, and addressing patient and caregiver psychosocial and spiritual needs. 7,8,13,14 We revised our institution's comfort care order set to create resources to individualize comfort care and align it with current pharmacologic principles. 10 The differences in moral distress between nurses and providers found in our and other studies might be further explained by the different roles these clinicians have in end-of-life care.…”

Section: Discussionmentioning

confidence: 99%

Moral Distress and Attitudes About Timing Related to Comfort Care for Hospitalized Patients: A Survey of Inpatient Providers and Nurses

Bender

Andrilla

Sharma

et al. 2019

Am J Hosp Palliat Care

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Context: Providing nonbeneficial care at the end of life and delays in initiating comfort care have been associated with provider and nurse moral distress. Objective: Evaluate provider and nurse moral distress when using a comfort care order set and attitudes about timing of initiating comfort care for hospitalized patients. Methods: Cross-sectional survey of providers (physicians, nurse practitioners, and physician assistants) and nurses at 2 large academic hospitals in 2015. Providers and nurses were surveyed about their experiences providing comfort care in an inpatient setting. Results: Two hundred five nurse and 124 provider surveys were analyzed. A greater proportion of nurses compared to providers reported experiencing moral distress “some, most, or all of the time” when using the comfort care order set (40.5% and 19.4%, respectively, P = .002). Over 60% of nurses and providers reported comfort care was generally started too late in a patient’s course, with physician trainees (81.4%), as well as providers (80.9%) and nurses (84.0%) < 5 years from graduating professional school most likely to report that comfort care is generally started too late. Conclusions: The majority of providers and nurses reported that comfort care was started too late in a patient’s course. Nurses experienced higher levels of moral distress than providers when caring for patients using a comfort care order set. Further research is needed to determine what is driving this moral distress in order to tailor interventions for nurses and providers.

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Section: Discussionmentioning

confidence: 99%

Moral Distress and Attitudes About Timing Related to Comfort Care for Hospitalized Patients: A Survey of Inpatient Providers and Nurses

Bender

Andrilla

Sharma

et al. 2019

Am J Hosp Palliat Care

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“…Indicating the complexity of conversations. 24 The utilization of the ACP/GOC note type is not mandatory by health-care providers in our hospital. However, uptake of this note type has been incremental over the last 2 years, with the majority of notes written by clinicians on the palliative care team, intensivists, general internal medicine teams, and social workers.…”

Section: Comfort Measures Order Set With Cied Deactivation Embeddedmentioning

confidence: 99%

Quality dying: An approach to ICD deactivation in the hospital setting

Turner

Torabi

Stilos

2020

Am J Hosp Palliat Care

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Background: In Canada, cardiovascular disease is the second most common cause of death. A subset of these patients will require a cardiovascular implantable electronic device (CIED). An estimated 200 000 Canadians are living with a CIED. CIEDs can improve life and prevent premature death. However, when patients reach the end of their lives, they can pose a challenge. An example of which is a painful shock delivered from an implantable cardioverter defibrillator (ICD) for an arrhythmia in a dying patient. Receiving a shock at the end of life (EOL) is unacceptable in an age when we aim to ease the suffering of the dying and allow for a comfortable death. Methods: As a quality standard of practice, all clinicians are expected to engage in EOL conversations in patients requiring CIED deactivation. Due to the potential discomfort of an ICD shock, specific conversations about deactivation of an ICD are encouraged. A process improvement approach was developed by our hospital that included an advance care planning simulation lab, electronic documentation and a standardized comfort measures order set that includes addressing the need for ICD deactivation at EOL. Results: EOL conversations are complex. Health care providers have been equally challenged to have conversations about ICD deactivation. Standardization of the process of ICD deactivation ensures an approach to EOL which respects the individuality of patients and promotes quality dying. Conclusion: Our hospital is committed to assisting clinicians to provide quality care by improving conversations about EOL care. On the basis of a synthesis of existing literature, we describe the importance of and the ideal process for having EOL conversations in patients about ICD deactivation at the EOL.

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“…Implementation of the CMOS is reinforced through consistent mentorship and follow-up by the PCCT, who often provide guidance in the initiation of the CMOS to the admitting service, or activate the order set themselves. [8] While nurses strive to provide good palliative care, the acute care ward in often busy, challenging nurses to provide the needed time and attention to dying patients and their families. [9] Acute care nurses are the crux in providing end of life care; yet, Steinhauser [10] found most health care providers receive EOL education informally.…”

Section: Introductionmentioning

confidence: 99%

A QI initiative to enhance nurses comfort level in providing EOL care on a general internal medicine ward

Stilos

Wynnychuk²

2021

JNEP

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Background and objective: Ideally, nurses should have acquired the knowledge and skills to provide not only pain and symptom management, but emotional support to dying patients and their families. In actual fact, nurses often feel under-educated, under-skilled, inexperienced and uncomfortable in providing comprehensive end of life care. A standardized protocol for assessing imminently dying patients’ symptoms and psychosocial needs was implemented at a tertiary academic hospital. The aim of this quality improvement initiative was to enhance the education and training of nurses on one acute care ward, around the implementation of the Comfort Measures Order Set for end of life care, specifically focusing on the provision of emotional support for dying patients and their families.Methods: Education sessions were offered to the nurses on one acute care ward as the study intervention, and the initial phase of one PDSA cycle. Descriptive statistics were used to analyze questionnaire responses; content analysis was used in reviewing the qualitative data.Results: Pre-intervention, over 70% of nurses did not feel comfortable providing emotional support to dying patients for whom the Comfort Mesaures Order Set was initiated. Post-intervention, nurses reported being more comfortable and knowledgeble.Conclusions: The goal of comfort care at end of life requires the skilled use of the Comfort Measures Order Set. The Advance Practice Nurse role, as part of the Palliative Care Consult Team, is specialized in providing emotional support to patients on comfort measures through research, theory development, education, practice, collaboration, and leadership across the institution.

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The Comfort Measures Order Set at a Tertiary Care Academic Hospital: Is There a Comparable Difference in End-of-Life Care Between Patients Dying in Acute Care When CMOS Is Utilized?

Abstract: Implementation of the CMOS is helpful in providing a foundation to a comfort approach in imminently dying patients. However, more education on its utility as a framework for EOL care and assessment across the organization is still required.

Cited by 17 publications

References 31 publications

Moral Distress and Attitudes About Timing Related to Comfort Care for Hospitalized Patients: A Survey of Inpatient Providers and Nurses

Moral Distress and Attitudes About Timing Related to Comfort Care for Hospitalized Patients: A Survey of Inpatient Providers and Nurses

Quality dying: An approach to ICD deactivation in the hospital setting

A QI initiative to enhance nurses comfort level in providing EOL care on a general internal medicine ward

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