"We'll be caring for a patient with end-stage renal disease who may be making the transition to comfort care today," I said to my orientee, an experienced nurse new to our unit.

"How do you handle that here?" she asked.

"We talk with the doctors and make sure everyone is on the same page," I explained. "When the patient's family arrives today, there shouldn't be any mixed messages!"

Our patient—I'll call him William Connor—was a World War II veteran. He had already discussed his condition and the withdrawal of life support with us. After reassessing him, we knew he was at peace with the decision he and his wife had made. He was tired of living in a hospital bed, and wanted to be "set free."

The birth of an idea

The next step in fulfilling our patient's wishes was to ask his physicians to prescribe an analgesic infusion, in case he developed pain or discomfort later on. Then we set up a time for the doctors to talk to Mr. Connor and his wife about what was happening and how our plan of care would unfold. "The most important thing," I stressed to my colleague, "is to ensure open communication."

After the healthcare team discussed which analgesic to prescribe, and the concentration of the infusion, we addressed what else needed to be done. At that moment, I realized that something was missing from the end-of-life care we provided our veterans: a set of guidelines that our staff could turn to in these types of situations. I kept that idea in the back of my head while I continued with the arrangements for Mr.
Connor.

Later that morning, while speaking with the patient's wife, I realized something else. Our end-of-life care would have to include more detailed patient education. When I'd explained that the transition to comfort care would include discontinuing the norepinephrine (Levophed) infusion that was maintaining her husband's blood pressure, and initiating a morphine drip, Mrs. Connor had become upset. She had strong preconceptions regarding "morphine drips," and feared that her husband would be "drugged" and unable to communicate with her in his final moments.

Clearly, we needed to help patients and their families better understand the dying process. We had to explain what would happen when the vasopressor infusion was stopped, the ventilator turned off, and the morphine drip started; what sort of physiological changes the patient would feel and the family would observe; what was going to happen at the actual moment of death; and at what point funeral arrangements could begin. Most important, we needed to reassure loved ones that we would start the morphine infusion only if the patient appeared to be in distress.

After listening carefully to the Connors' concerns, we answered their questions and began the transition. As we turned off the norepinephrine, our patient became restless and unable to talk lucidly with his wife or the healthcare team. Mrs. Connor asked that we start the morphine drip, and once we did, her husband appeared more relaxed and peaceful. She, too, seemed more at ease.

The orientee and I made a point to check on the patient's wife as often as we checked on the patient, offering support and a sympathetic ear. Before our shift ended, Mr. Connor died. Prior to leaving, Mrs. Connor expressed how much she appreciated the care and compassion we'd shown them.