Sunday, March 13, 2011

What to do after the patient is made comfort measures only (CMO)

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By Robert Arnold, MD
Vol 11, No. 2 - February 2011

Case:  The patient is a 75-year-old man who presented with a severe headache and syncopal episode.  His past medical history is remarkable for diabetes, hypertension, hyperlipidemia and an MI in 2009. His family brought him to his local emergency room where it was noted that he had a blown right pupil, and CT scan revealed a large subarachnoid bleed.  He was intubated and life flighted to the hospital.  There he was seen by neurology and neurosurgery, and it was determined that he was not a surgical candidate.   Over the next three days he had little neurological improvement, and after meeting with the family it was decided that he should be made comfort measures only.  He was extubated and 24 hours had stable vital signs, although he was still comatose.  The neurology and neurosurgery team are unclear about what should happen next or about the topics that need to be discussed with the family.
Discussion:  Deciding to focus only on comfort is a major transition point for patients, families and health care providers.  After making this decision, most families are not sure what comes next.  They look to health care providers to reassure them that they are doing the right thing and to ensure that their loved one does not suffer and that they are prepared for the next few days. The following questions should guide one’s action after a patient is made CMO:
1.   Are the patient’s symptoms adequately treated/prevented?
UPMC Health System has developed a comfort measures only order sheet in order to optimize symptom management in CMO patients. (see order on demand). It reminds clinicians that:
a.    All medications and laboratory tests that do not promote comfort should be discontinued.
b.   Most patients near the end of life are not awake enough to tell us when they have symptoms.  Instead, clinicians should treat nonverbal signs such as  rapid respiratory rate (>24/minute), grimacing, moaning, and restlessness presumptively as signs of discomfort or shortness of breath.
c.    The appropriate medications to treat pain or shortness of breath are opiates.
To promote rapid control of symptoms, prn opiates can be titrated rapidly (every 15-30 minutes for iv dosage and 60 minutes for oral opiates.) An infusion may be started if the patient has active symptoms requiring several boluses.
d.   Terminal delirium is treated using benzodiazepines.
e.    The only evidence-based treatment for secretions, or “the death rattle,” is glycopyrrolate.
2.   Does the family want information about what they are likely to see as their loved one dies?
Most families do not have a great deal of experience with death and dying.  It is appropriate to ask them if they would like to hear what they are likely to see over the next hours/days. This information may decrease their fear of the unknown and reassure them that their loved one is “on the right trajectory” and not suffering.  For example, one can tell families that as patients die it is normal that: 1  
a.    They are less responsive and sleep most of the time. Hearing may persist, however, and thus families should feel free to talk to their loved one.
b.   They eat and drink less.  This is not uncomfortable and good mouth care relieves any thirst the patient may have.
c.    Their urine output will decrease, and their hands and feet may become cool.
d.   Their breathing may become irregular with periods of apnea.
e.    They may begin to “gurgle.” This is not uncomfortable to the patient but can be distressing to families who are worried that their loved one is “drowning.” Drawing an analogy to snoring may be helpful.
Finally, families often want to know how long their loved ones will live.  This is an extraordinarily difficult question because of our limited ability to prognosticate the exact time of death.
(Our ability to predict the time of death is no better than our ability to predict the time of birth–we can set boundaries but not determine exact times). Acknowledge your uncertainty, and then give your best judgment–whether hours to days or days to a week or two. Asking the family if they have any specific concerns is often helpful.
3.   Does the patient or family have religious traditions that the health care team should be aware of?
Ask the family whether there are any spiritual or religious traditions that are important to them or their loved one.  In Western Pennsylvania, the most common tradition one needs to be aware if is Catholic need for Sacraments of the Sick prior to death. The chaplaincy service at many hospitals is available 24/7 to meet with families and provide support.
4.   Is there anyone else who needs to come and say goodbye?
It is useful to ask families whether there is anyone else who would like to say goodbye to their loved one.  In addition, families are often unsure what or how much to tell children about their loved one’s dying or whether to let them see them. Asking about this issue allows the family to express their discomfort and ask questions. This is a complicated topic about which social workers often have particular expertise.2
5.   What dispositional issues should be discussed with the family?
There are three general options for patients who have been made CMO:
a.       The family may wish to stay in the hospital, either with or without hospice.  Given that roughly 70% of patients die within 24 hours of having life sustaining treatments stopped in the ICU, this is a reasonable option for the first day.  Staying in the hospital for longer periods may not be the best option as the staff have competing responsibilities, hospitals are not set up to focus solely on comfort, and many hospitals have a 2-3 day time limit for in-hospital hospice.
b.      For patients who have symptoms and are actively dying, the most appropriate location may be an inpatient hospice unit (either a stand alone unit or located in a long term care facility). These units are staffed by hospice nurses, social workers, and physicians and provide excellent palliative care as well as attention to families’ psychosocial and religious needs. There are a number of these units within Western Pennsylvania.
c.       Taking the patient home with hospice may also be a good option for families, provided they have enough support and are willing to have their loved one at home.  It is important to remember that when a patient is at home, hospices provide roughly 2-4 hours of care a day depending on the patient’s needs.  Thus, the family needs to understand and be willing to provide basic comfort care for their loved one (with direction and guidance from the hospice).
Which options are available and will fit the patient/family needs will vary depending on the patient’s clinical status, the insurance, and family situation.  Care managers and social workers in most units are knowledgeable about these issues and can help guide the family about the appropriate choice given their values.  Given this, it is important to have them meet with the family shortly after the patient is made CMO.  In difficult or complex cases, the palliative care social workers are available for consultation and help.
1.   The palliative care service can provide teams with informational brochures that describe the dying process.
2.   The palliative care service has reading material that they can provide to the primary service to give to families.

16 Responses to “What to do after the patient is made comfort measures only (CMO)”

Christian Sinclair said...
March 13, 2011 at 5:49 PM

I have never seen the abbreviation CMO meaning comfort measures only. In the hospitals I have worked at we usually wrote out comfort care only. Is that a common abbreviation or maybe just used in Pittsburgh? What does your hospital use?

Flannery Fielding said...
March 14, 2011 at 6:49 PM

In my limited experience (two large teaching hospitals in Los Angeles), CMO is a commonly used term - although less commonly implemented. I've heard comfort care only used as well, and I appreciate it as highly descriptive, not overly clinical and easy for families to understand.

I have a question about one of the points in the case study - I followed the link but wasn't able to find the original post, which I presume may have included citations. In the first point in the discussion section, it is stated "The only evidence-based treatment for secretions, or 'the death rattle,' is glycopyrrolate." Having done a fair bit of research on this topic over the past several months, I'm surprised to hear there's an evidence base for using glycopyrrolate over any of the other commonly used anticholinergics. My understanding had been that essentially all of the pharmacologic treatments we use for death rattle are equally ineffective (although not all the researchers involved have chosen to put that spin on it). Is this new data? Can anyone out there point me in the direction of the evidence for glycopyrrolate?

Suzana Makokwski said...
March 14, 2011 at 7:58 PM

I had not seen CMO until I returned to the east coast after some time away. I was a little confused the first time seeing it, wondering why someone would comment on the Chief Medical Officer in a patient's chart - sometimes associated with a new form of "code status" implying thatNOW the patient had permission to die in the hospital; other times meaning Continuous Morphine Only, as if suddenly morphine became this wonder drug that alleviated all symptoms, all evil. I would explain to people that if that were the case, fellowship and boards in palliative care would be a peace o' cake.
So thanks for the blog, Bob, and for the comment, Christian!

Christian Sinclair said...
March 14, 2011 at 8:10 PM

I totally thought CMO meant Chief Medical Officer too. I bet having to go see the Chief Medical Officer is not like Comfort Measures Only.

Dslawton said...
March 14, 2011 at 8:17 PM

In regards to the "death rattle" I think that educating the family and correct positioning of the patient are key. I would explain to the family what the noise meant by saying that it is simply air passing through the accumulation of saliva at the back of their loved ones throat. I would talk about how as we die the ability to swallow is decreased so we are no longer able to handle all of the secretions that are normally produced. I would instruct them to look for signs of distress instead of focusing on the sound of the gurgling. Look for facial grimacing, picking at badsheets, etc. If the patient seemed breathless then it might be appropriate to administer liquid morphine which would increase their tidal volume and allow them to take a bigger breath thus decreasing their rapid rate. Then I would position the patient on his side with his head down and a towel under his mouth. Doing this facilitated the drainage of secretions. It seems counterintuitive because most want to put the patient's head up but without the ability to swallow that simply promotes pooling which causes the rattle. Rarely did families ever worry about the noise anymore because they could understand what was causing it and they were no longer fixated on it.

Christian Sinclair said...
March 14, 2011 at 8:27 PM

Excellent comment Dslawton. I agree with a lot of the education points you made. Caution is important though when using PO/SL medications anytime there is evidence of impaired swallowing or noisy secretions/death rattle. If other routes are easily available like IV or subcutaneously (under the skin) then one might consider those, but obviously those are usually only available in a facility like a hospice house.

Dslawton said...
March 14, 2011 at 8:45 PM

Agree with being careful about administering sl meds. I think the 0.5ml, which is usually all that is needed, can be given easily by giving a few drops at a time while the patient is lying on their side.

Suzana Makokwski said...
March 14, 2011 at 8:53 PM

Pharmacology does not "stop" just because someone is 'CMO', and efficacy of medications for difficult to manage saliva or pooling of secretions do not change eith. Despite the limit data expressed in the Cochrane study that only reviews literature done on patients who were identified as actively dying, anticholinergics have been studied more broadly in as variety of neurological conditions that mimick the lack of gag reflex at the end of life - such as with ALS and other neurologic conditions.
The research supporting glycopyrrolate, as Bob Arnold writes, is quite substantial, actually. It's pharmacology also gives us more room to increase dose, perhaps leading to increased efficacy. Unlike other anticholinergics available in the US, it is a quaternary amine, hydrophilic, and thus, does not cross the blood-brain-barrier lessening the risk of medication induced delirium.
In the UK there is a quaternary amine version of scolopamine as well.
Repositioning, minimizing excess fluids (in feeding tubes, Ivs) can help, but sometimes we need a little help from Pharm.
A great overall reference is - free signup.

Christian Sinclair said...
March 14, 2011 at 9:14 PM

Since the effect of opioids may be different based on patients previous exposure and tolerance, it depends on the right amount. So the answer to anyone here reading none of this is medical advice. Please talk with your doctor or nurse who can best apprise the situation in front of you.

Christian Sinclair said...
March 14, 2011 at 9:16 PM

Thanks for the great reply Suzana.

Flannery Fielding said...
March 14, 2011 at 9:33 PM

Thanks for sharing your approach to dealing with death rattle - very practical and clearly compassionate. One point from the Cochrane review that I found fascinating: the actual cause of death rattle is, in fact, uncertain. The mechanism as you've explained it (and as many of us do) is presumed, not proven. So, as an additional educational intervention with families, we might addend our explanation with a caveat.

Flannery Fielding said...
March 14, 2011 at 9:46 PM

Great information - thank you!

Christian Sinclair said...
March 14, 2011 at 10:19 PM

I would love to see a lot more research in this area. Even a comprehensive agreed upon grading system would be good so we can all be talking about the same thing.

David Fisher MD said...
March 15, 2011 at 10:52 PM

Good information here, and thank you. I will just nitpick on my one pet peeve. I never liked the phrase "patient was made comfort measures only" or "patient was made DNR". It is too pejorative, and actually inaccurate, to state things this way, considering that most of these decisions are made with the patient, or a surrogate who is attempting to honor the patient's wishes. As a patient or family member, hearing that someone was "made comfort measures" could imply unilateral decision-making on the part of the clinicians. It could also imply that the patient could have been "made curative care" or even "made to walk again", but the doctors chose a different course. Indeed, I often wish I had more power as a doctor, but I cannot "make" my patient respond to my treatment plan any more than I can "make" their disease progress to the point that comfort measures are the best option. I much prefer saying that "the patient (or family) elected comfort measures only." (In the same vein, I avoid saying that my patient "is a DNR." He or she is a person who has a DNR order.)

Christian Sinclair said...
March 16, 2011 at 9:59 AM

Great points about semantics David. I had never thought that clsoely about
saying/writing things like 'The patient is (a) DNR?' but now with your
comments, it actually looks very objectifying and dehumanizing. I
appreciate your insight and will start to correct some of those habits and
use that in teaching as well.

Cyndi Cramer said...
March 20, 2011 at 7:45 PM

We use CMO orders in our Tampa hospital. I know a search was done before initiating that and the searchers found "many places" that were using this...but I'm afraid I don't have the details...