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Background: Palliative care aims to reduce pain and suffering in patients and their families by a thorough assessment and treatment of physical, psychological, and spiritual symptoms. As a patient's death approaches, his or her symptoms may necessitate more aggressive palliation. Support for the dying patient's family should increase as comfort measures become more intense. Palliative care after a patient's death is largely concerned with bereavement and family assistance. Palliative care near the end of life requires assisting patients and their families in understanding the nature of their illness and prognosis. Palliative care professionals can assist patients and their families in determining appropriate medical care and aligning the patient's care goals with the healthcare team's aims. Finally, palliative care at the end of life requires determining the need for a medical proxy, advance directives, and resuscitation status. Physical pain, as well as substantial emotional, spiritual, and social misery, may be present in patients throughout their final hours and days. As death approaches, patients in their final days require careful symptom control, and families may need support and guidance. After the death is announced, the family is notified, and grieving support is provided, the care continues.

Background: It is not clear whether use of specialty palliative care consults and “comfort measures only” (CMO) order sets differ by type of intensive care unit (ICU). A better understanding of palliative care provided to these patients may help address heterogeneity of care across ICU types. Objectives: Examine utilization of specialty palliative care consultation and CMO order sets across several different ICU types in a multihospital academic health care system. Design: Retrospective cohort study using Washington State death certificates and data from the electronic health record. Setting/Subjects: Adults with a chronic medical illness who died in an ICU at one of two hospitals from July 2013 through December 2018. Five ICU types were identified by patient population and attending physician specialty. Measurements: Documentation of a specialty palliative care consult during a patient's terminal ICU stay and a CMO order set at time of death. Results: For 2706 eligible decedents, ICU type was significantly associated with odds of palliative care consultation (p

Sleep is a vital component of health and healing. Hospitalized patients need sleep in order to overcome their illness, and family members of those patients also need restorative sleep. Nurses can assist with both patient's and family member's abilities to obtain nonfragmented sleep. Education is important for families to understand the importance of sleep, and nurses can also supply families with simple comfort measures such as ear plugs, eye masks, and a comfortable sleep location.

Several research studies have shown that code status documentation is misinterpreted or incorrectly defined by a significant number of medical professionals. This misinterpretation among the medical team (i.e. equating Do Not Resuscitate (DNR) with comfort care measures only) may lead to false reporting, poor symptom management, and potentially adverse clinical outcomes. Most Hospice and Palliative Care providers are aware of these distinctions, however a shortage (and continued foreseen shortage) of Hospice and Palliative Care providers may mean these conversations and distinctions will fall to non-subspecialists, or providers of other medical specialties or degrees. The literature has demonstrated that these shortfalls and misinterpretations are present and constitute potential harm to our patients.

This multi-component educational intervention was aimed at General Internal Medicine residents’ perceived self-efficacy in providing end of life care. This study also measured the uptake of the Com...

Preventing pressure injuries and wound deterioration can be challenging for the patient at the end of life. Pressure injuries are often deemed unavoidable when a patient is actively dying; however, the time frame for this process is variable. As the skin fails in an actively dying patient, interventions should align with the patient and family's goals. This integrative literature review defines essential concepts to pressure injury and wound management during this final stage of life including (1) actively dying, (2) end of life, (3) palliative care, and (4) comfort measures. We also provide clinically relevant, evidence-based recommendations for pressure injury prevention and wound management of the patient who is actively dying.

We sought to describe long-term outcomes of infants with severe surgical necrotizing enterocolitis (NEC).Data were collected on infants with surgical NEC (2009-2018). Severe surgical NEC was defined by extensive bowel loss with residual bowel length30 cm, and "NEC totalis" was identified per operative report. Post-operative management and long-term outcomes were assessed, including enteral autonomy, severe neurodevelopmental disability, and educational attainment.Of 268 infants with surgical NEC, 41 (15%) had severe surgical NEC, and 14/41 were identified as "NEC totalis". Zero severe NEC vs. 8 (57%) "NEC totalis" patients were placed on comfort measures following initial surgery (p 0.001). Twenty-five patients (93%) with severe NEC survived vs 3/6 with "NEC totalis" (p 0.001). The 28 survivors (68%) were followed for a median (IQR) duration of 8(4,10) years. Nine (32%) with severe NEC were weaned from parenteral nutrition. Eight (29%) had ≥1 marker for severe neurodevelopmental disability, and 11/16(69%) (7-16 years) were attending school at last follow-up.Long-term survival is excellent following initial discharge, and achievement of enteral autonomy is feasible in patients with severe surgical NEC. The majority of patients who survive do not have severe neurodevelopmental disability and participate in school. Given current survivals and outcomes, focus on measured residual bowel length may be more appropriate than the subjective term "NEC-totalis."Prognosis Study.Level II.

RESUMEN: Objetivo: Describir la relación entre el personal de enfermería y las gestantes durante el trabajo de parto, desde la perspectiva de la mujer. Métodos: Estudio descriptivo y transversal. Se incluyó el 92,4% del total de las gestantes en trabajo de parto atendidas en una institución de salud de la ciudad de Medellín, entre los meses de junio y julio de 2017. Se aplicó un cuestionario ad hoc, diseñado a la luz de las fases de la relación interpersonal enfermera paciente, descritas por Hildegard Peplau, el cual fue sometido a una prueba piloto y concepto de cinco expertos. Se aplicaron pruebas chi-cuadrado y se construyó un modelo de regresión logística. Resultados: Participaron 540 mujeres con edad promedio de 25,6 años (DE 6,0). El 91,9 % valoran como positiva su relación con la enfermera. Se encontró que, a mayor edad de la gestante, mejor comunicación con el personal de enfermería (X2 = 15,9 p= 0,003) y que las madres con parto previo tuvieron una mejor experiencia frente al cuidado (X2 = 4,28 p= 0,038). La regresión logística mostró (90% de confianza) que una relación positiva con el personal de enfermería en el parto está relacionada con: la edad (OR=0,9, IC = 0,867 – 0,989), aclarar las dudas frente al parto (OR=18,0, IC = 6,641 – 48,938), evitar el frío (OR=6,1, IC =2,347 – 16,3) y la ayuda para tranquilizarse (OR=4,1, IC = 1,45 – 11,714). Conclusión: Durante el cuidado de la gestante en trabajo de parto, es importante aclarar las dudas, brindar medidas de confort y generar estrategias para tranquilizarla, así como para establecer una relación interpersonal positiva en la experiencia del trabajo de parto. ABSTRACT: Objective: Describe the relationship between the nursing personnel and the expecting mothers during labor, from the perspective of women. Methods: Descriptive and crosssectional study. From the total expecting mothers, 92,4% were included during labor and were attended in a healthcare institution in the city of Medellin between the months or June and July, 2017. A type ad hoc questionnaire was applied, designed in light of the phases of the interpersonal relationship between the nurse and patient, described by Hildegard Peplau, which was subject to a pilot experiment and concept of five experts. Chi squared tests were applied and a model or logistic regression was built. Results: 540 women participated with an average age of 25,6 years (SD 6,0). 91,9% rate as positive their relationship with the nurse. It was found that the older the expecting mother is, the better the communication with the nursing personnel (X2 = 15,9 p= 0,003) and also that mothers with previous births had a better experience of care (X2 = 4,28 p= 0,038). The logistic regression showed (90% reliability) that a positive relationship with the nursing personnel during birth is related to: age (OR=0,9, IC = 0,867 – 0,989), clarifying questions about giving birth (OR=18,0, IC = 6,641 – 48,938), avoid coldness (OR=6,1, IC =2,347 – 16,3) and help the mother to be calm (OR=4,1, IC = 1,45 – 11,714). Conclusion: During the care for the birth of the expecting mother, it is important to clarify questions, provide comfort measures and generate strategies to calm the mother, as well as to establish a positive interpersonal relationship during the birth experience. COL0146822

I.V. catheter placement is one of the most common causes of procedural pain in children. Interventions to address this pain are readily available but inconsistently used in practice. The focus of this article is to identify and encourage best practice for pain mitigation in peripheral I.V. catheter placement in children.

Background: Antibiotic use may increase hospital length of stay (LOS) among older patients with advanced cancer who are transitioned to comfort measures. Methods: We studied a cohort of patients with advanced cancer aged ≥65 years who were transitioned to comfort measures during admission from July 1, 2014, through November 30, 2016. We evaluated the association between antibiotic exposure and LOS using a Poisson regression model adjusted for age, gender, cancer type, comorbidities, infection, and intensive care unit admission. Results: Among 461 patients with advanced cancer, median age was 74 years (range: 65-99), 49.0% (n = 226) were female, and 20.6% (n = 95) had liquid tumors. Overall, 82.9% (n = 382) received ≥1 antibiotic and 64.6% (n = 298) had ≥1 infection diagnosis during hospitalization. Infection diagnoses commonly included sepsis (35%, n = 161/461), pneumonia (25%, n = 117/461), and urinary tract infection (14%, n = 66/461). Among those receiving antibiotics, the most common choices included vancomycin (79%, n = 300/382), cephalosporins (63%, n = 241/382), and penicillins (45%, n = 172/382). In a multivariable Poisson regression model, LOS was 34% longer (count ratio = 1.34, [95% confidence interval: 1.20-1.51]) among those exposed versus unexposed to antibiotics. Conclusions: Antibiotic use among patients with advanced cancer who are transitioned to comfort measures is associated with longer LOS. These data illustrate the importance of tradeoffs associated with antibiotic use, such as unintended increased LOS, when striving for goal-concordant care near the end of life.

Bartholin duct cysts and gland abscesses can affect a woman's day-to-day functioning and be challenging to manage. Many Bartholin duct cysts that are not infected remain asymptomatic and resolve spontaneously without intervention. However, an infected Bartholin duct cyst or glandular abscess should be drained when larger than 2 cm because such cysts or abscesses do not tend to resolve spontaneously and can recur. Management options fall under 3 broad categories: expectant, medical, or surgical. With special training, midwives and women's health nurse practitioners can manage many women who present with Bartholin duct cysts or gland abscesses. Rarely, a woman with a severe or recurrent infection will need referral to a surgeon. Knowing which management option to choose may be challenging at first; this article is aimed at providing evidence-based knowledge about Bartholin duct cysts and gland abscesses for clinicians so that they can make the diagnosis and management plan with confidence. A clinical case is used to illustrate the identification, diagnosis, and management of Bartholin duct cysts and gland abscesses. The range of interventions, from expectant management with comfort measures to surgical intervention, is be explored to assist the clinician in choosing the correct management approach.

A Form for Re-Intubation Evaluation by Nurses and Doctors (FRIEND) was used to prospectively collect pre-extubation data, to determine failure of extubation (FOE) risk.FRIENDs, including airway, breathing, and neurologic variables, were completed before extubation on traumasurgical patients in one ICU from 1/1/16 to 5/31/17. Those with failed vs. successful extubation were compared. We excluded those with tracheostomy, comfort measures, or death before extubation.There were 464 eligible extubations in 436 patients. Thirty five reintubations (7.9% FOE rate) occurred in 32 patients within 96 h of extubation. FOE patients had higher ICU days (6 d vs. 2 d), ventilator days (6 d vs. 2 d), and mortality (15.6% vs. 2.7%) [all p 0.001] compared to those without FOE. Odds of FOE (OR [CI]) increased with age (1.03, [1, 1.06]), delirium (3, [1.16, 7.76]), moderate/copious secretions (3.95, [1.46, 10.66]), and enteral opioid use (4.23, [1.28, 14.02]).Several characteristics present at the time of extubation were risk factors for FOE in trauma and surgical patients. Patients with FOE had higher mortality.

Background and Aims Average life expectancy have been continuously increasing within the general population and, equally so, within Nephrology patients. End-of-life (EOL) care is part of non-oncologic palliative care provided by Nephrology. The aim of our study is to evaluate the quality of EOL care provided in Nephrology, and to determine potential areas of improvement. Method Retrospective single-centre analysis of all nephrology and kidney transplant inpatients dying between January 2019 and June 2020. Clinical records were reviewed for evidence of recognition of end of life, resuscitation plans, acute interventions in the 48 hours previous to death, comfort care plans and symptoms evaluation. Results A total of 83 patients were included. 19.6% of patients had chronic kidney disease, 60.2% were in haemodialysis, 14.5% were kidney transplanted patients and 3.6% had acute kidney injury. 89.2% of the admissions were for acute events, 5% for symptom control and 4.8% for diagnosis. In 72.3% of admissions, EOL was recognised. Most patients were unable to discuss EOL plans (67.5%), and the family was informed of the prognosis in only 61.4% of the cases. At the time of dead: only 62.7% of patients had a clear resuscitation plan, 44.6% were on antibiotics and 26.5% died with nasogastric tube. Within 48h of death: invasive interventions were still being given in 42.2%, blood samples were taken in 69.9%; imaging was performed in 36.1% and 48.2% had a haemodialysis session. Comfort measure were provided to 53% and only 60.2% had evidence of symptom evaluation. 44.6% stopped invasive measures in the last 48h. Recognition of EOL was associated with having a clear resuscitation plan (p In a multivariable analysis (binary logistic regression), EOL recognition was associated with a clear resuscitation plan (Exp(B) 0.088, (CI 95%: 0.018-0.419) p=0.002), with discussion of prognosis with family ( Exp(B) 0.061 (CI 95%: 0.011-0.337) p=0.001), and with reduced body mass index (Exp(B) 0.870, (CI 95%: 0.763-0.991), p=0.037,); in a model adjusted to the age. Conclusion In our cohort, patient for whom EOL was recognized had better EOL care. In conclusion, there are still areas in which EOL care can be improved. Palliative care should be an investment area for training within the Nephrology core curriculum and awareness for EOL care is needed.

Doulas are specialized caregivers who provide emotional support, information, comfort measures, and advocacy to women during their childbearing year, with a focus of continuous companionship during labour and delivery. This dissertation is a sociological study of the emergence of birth doulas as an occupation seeking legitimacy within maternity care. Findings are drawn from in-depth, semi-structured interviews conducted with twenty birth doulas from the same Midwestern metropolitan area in 2012-2013. Doulas in this sample, both volunteer and paid, ranged in certification status, birth experiences, and encounters with medical staff. An interview was also conducted in 2011 with two key informants from the largest doula membership organization. This study addresses a gap in the literature on professionalization to account for the expanding doula occupation seeking legitimacy. The findings demonstrate many ideological tensions and paradoxes of how doulas strive to establish themselves as professionals. I find that the demands of professionalization may contradict the very essence of doula work. This creates tension between pursuing legitimacy while still desiring autonomy and self-regulation. Another paradox is how doulas need support in order to give support. Inadequate theories of worker emotion management provide an opening to discuss doulas' needs for peer support. I find that although doula work is mostly solo and isolating, there persists a strong need for collegiality. Doulas especially find benefits to debriefing with other doulas or birth workers when they are no longer with a client. I expand Goffman's concept of teammates, who co-operate on stage in performance and gossip back stage, to include doulas need for such support when they are not working in order to be successful caregivers. Clinical research has found the presence of a doula is associated with more positive birth experiences and outcomes. However, very little is known about which types of social support that doulas provide contributes to improving health outcomes. I analyzed a sample of 198 clients who received one of 85 volunteer doulas in 2005-2007. I ran logistic regression to demonstrate that when volunteer doulas of similar training provide massage and visualization/relaxation, women have a significantly lower risk of having an unexpected c-section.

Introduction/Objective Heterotopic mesenteric ossification (HMO) is a rare, reactive condition involving abnormal bone formation within the mesentery. While its etiology is uncertain, reports suggest two possible inciting events - either metaplasia from trauma and/or inflammation or dislodgment of bone fragments from other sites during abdominal surgery. With less than 50 reported cases, there is much unknown about this disease process. Herein, we present a rare, fatal case. Methods/Case Report A 43-year-old man with a history significant for Crohn’s disease status-post multiple abdominal surgeries and with resultant chronic abdominal pain was found unresponsive at home by family with an unknown downtime. He was taken to the local hospital where he was admitted to the Intensive Care Unit. Given a poor prognosis, family transitioned him to comfort care measures and he died shortly thereafter. Autopsy examination revealed a thin man with an ostomy and severe abdominal scarring. Internally, there were multiple aberrant bone fragments within the mesentery which neither perforated the bowel nor caused obstruction and which microscopically appeared to be mature and benign. Ancillary studies were significant severe dehydration. Follow-up conversation with his family revealed that due to debilitating abdominal pain, the decedent had significantly decreased his oral intake and had stopped taking medications to control his high output ostomy. Given the autopsy and investigative findings his death was certified as a natural death caused by dehydration due to complications of Crohn’s disease. Conclusion This is the first reported case of HMO occurring in inflammatory bowel disease. Awareness of this condition is important for clinicians as it can alter management of these patients. Early review and recognition from radiologists and pathologists can potentially improve the morbidity and mortality of this group.

BACKGROUND: POLST is widely used to document the treatment preferences of nursing facility residents as orders, but it is unknown how well previously completed POLST orders reflect current preferences (concordance) and what factors are associated with concordance. OBJECTIVES: To describe POLST preference concordance and identify factors associated with concordance. DESIGN: Chart reviews to document current POLST orders and interviews to elicit current treatment preferences. SETTING: POLST-using nursing facilities (n = 29) in Indiana. PARTICIPANTS: Nursing facility residents (n = 123) and surrogates of residents without decisional capacity (n = 152). MEASUREMENTS: Concordance was determined by comparing existing POLST orders for resuscitation, medical interventions, and artificial nutrition with current treatment preferences. Comfort-focused POLSTs contained orders for do not resuscitate, comfort measures, and no artificial nutrition. RESULTS: Overall, 55.7% (123/221) of residents and 44.7% (152/340) of surrogates participated (total n = 275). POLST concordance was 44%, but concordance was higher for comfort-focused POLSTs (68%) than for non-comfort-focused POLSTs (27%) (p < .001). In the unadjusted analysis, increasing resident age (OR 1.04, 95% CI 1.01 – 1.07, p < .01), better cognitive functioning (OR 1.07, 95% CI 1.02 – 1.13, p < .01), surrogate as the decision-maker (OR 2.87, OR 1.73 – 4.75, p < .001), and comfort-focused POLSTs (OR 6.01, 95% CI 3.29 – 11.00, p < .01) were associated with concordance. In the adjusted multivariable model, only having an existing comfort-focused POLST was associated with higher odds of POLST concordance (OR 5.28, 95% CI 2.59 – 10.73, p < .01). CONCLUSIONS: Less than half of all POLST forms were concordant with current preferences, but POLST was over 5 times as likely to be concordant when orders reflected preferences for comfort-focused care. Findings suggest a clear need to improve the quality of POLST use in nursing facilities and focus its use among residents with stable, comfort-focused preferences.

The concept of Palliative Care has evolved as an approach to provide comfort to patients and their families. These comfort measures not only include pain management but encompass ways to manage the psychosocial, physical, and social concerns that arise. Recently, the use of medical cannabis has come to the forefront of healthcare as a frequently requested medical therapy for the management of a variety of acute and chronic effects of illness. This chapter will explore the use of medical cannabis and the associated concerns that may arise when utilized in the Palliative Care setting. Using a case study approach, barriers, such as stigma, will be analysed for an adult, geriatric patient where medical cannabis is introduced into their plan of care. The benefits and disadvantages of the use of medical cannabis, related to the physical and psychosocial aspects of chronic illness and end-of-life care, will be examined.

The COVID-19 pandemic has reinforced the centrality and importance of fundamental and core nursing skills including everyday skills such as handwashing, infection control measures, patient safety and comfort measures (Alzyood, Jackson, Aveyard & Brooke, 2020; Cruickshank & Shaban, 2020). Since the beginning of the pandemic there have been concerns about the spread of COVID-19 in hospitals, aged care facilities and primary care settings, and infection rates among health workers, as well as the possibility that health workers have contributed to the spread of the infection in some settings (Davidson & Szanton, 2020; Jackson et al., 2020).

Background: Portable Orders for Life-Sustaining Treatment (POLST) are increasingly utilized to assist patients approaching the end of life in documenting goals of care. We evaluated the association of POLST, resource utilization, and costs to 1 year among injured older adults requiring emergency services.Methods: This was a retrospective cohort of injured older adults ≥65 years with continuous Medicare fee-for-service coverage transported by emergency medical services (EMS) in 2011 across 4 counties in Oregon. Data sources included EMS, Medicare claims, vital statistics, and state POLST, inpatient and trauma registries. Outcomes included hospital admission, receipt of aggressive medical interventions, costs, and hospice use. We matched patients on patient characteristics and comorbidities to control for bias.Results: We included 2116 patients of which 484 (22.9%) had a POLST form prior to 911 contact. Of POLST patients, 136 (28.1%) had orders for full treatment, 194 (40.1%) for limited interventions, and 154 (31.8%) for comfort measures. There were no significant associations for care during the index event. However, in the year after the index event, patients with care limitations had higher adjusted hospice use (limited interventions OR 1.7 [95% CI: 1.2–2.6]; comfort OR, 2.0 [95% CI: 1.3–3.0]) and lower adjusted post-discharge costs (no POLST, $32,399 [95% CI: 30,041–34,756]; limited interventions, $18,729 [95% CI: 12,913–24,545]; and comfort $15,593 [95% CI: 12,091–19,095]). There were no significant associations for all other outcomes.Conclusions: Care limitations specified in POLST forms among injured older adults transported by EMS are associated with increased use of hospice and decreased costs to 1 year.

Florence Nightingale, objeto de pesquisa de muitos estudiosos no mundo, desde o século XVIII vem contribuindo significativamente para o desenvolvimento da saúde hospitalar. O estudo tem como objetivo refletir objetivamente o discurso acadêmico sobre ambiente na perspectiva de Nightingale aplicada aos cuidados com os ambientes contaminados. Trata-se de estudo teórico-reflexivo, com abordagem qualitativa, fundamentado nas sólidas bases conceituais da Teoria Ambientalista de Florence Nigthingale, perenes nas concepções teóricas, paradigmas e discursos oficiais da literatura no período de 1972 a 2018, devidamente contextualizada e corroborada com as abordagens de recentes artigos sobre a temática publicados em periódicos internacionais da área de conhecimento. Os resultados apontam que (100%) dos estudos abordam o tema ambiente e se conectam com Nightingale e (33%) destacam a evolução das tecnologias, porém, as mesmas não se desarticulam do ambiente como espaço fundamental de seu uso. O estudo demonstra que os pilares da Teoria Ambientalista de Florence Nightingale, continuam vigentes, atualizados no concernente as suas preocupações com ambiente, cuidados para com os enfermos, medidas de conforto, prevenção de contaminações e doenças, mostrando que suas bases teórico-científicas se mantém vivas e imprescindíveis, ao longo de um século, notadamente referenciada no presente, além de promissoras influências futuras.

Objective To understand the use of tools, protocols and comfort measures related to sedation/analgesia, and to screen the occurrence of delirium in pediatric intensive care units. Methods A survey with 14 questions was distributed by e-mail to Brazilian critical care pediatricians. Eight questions addressed physician and hospital demographics, and six inquired practices to assess sedation, analgesia, and delirium in pediatric intensive care units. Results Of 373 questionnaires sent, 61 were answered (16.3%). The majority of physicians were practicing in the Southeast region (57.2%). Of these, 46.5% worked at public hospitals, 28.6% of which under direct state administration. Of respondents, 57.1% used formal protocols for sedation and analgesia, and the Ramsay scale was the most frequently employed (52.5%). Delirium screening scores were not used by 48.2% of physicians. The Cornell Assessment of Pediatric Delirium was the score most often used (23.2%). The majority (85.7%) of physicians did not practice daily sedation interruption, and only 23.2% used non-pharmacological measures for patient comfort frequently, with varied participation of parents in the process. Conclusion This study highlights the heterogeneity of practices for assessment of sedation/analgesia and lack of detection of delirium among critical care pediatricians in Brazil.

Neonatologists play a pivotal role providing consultation before and after delivery to expectant parents faced with threatened prematurity, congenital anomalies and genetic disorders, and birth injury. In addition to what to expect when having an infant in the neonatal intensive care unit (NICU), neonatologists must also include goals of care and whether intensive therapies alongside comfort measures are to be provided for life-threatening neonatal conditions. They must be flexible in adapting their consultation style according to the specific medical situation and needs of the expectant parents. Critical skills include what information to provide and how to relay it clearly, as well as how to elicit parents’ values and integrate them in decision-making.

Many people with implanted cardioverter defibrillators (ICDs) are living at home and receiving nursing services through home health care agencies. Near the end of life, it is not unusual for patients to request comfort measures and care that promotes quality rather than quantity of life. The purpose of this pilot study was twofold: (1) to educate home health care nurses on care of patients with ICDs nearing the end of life and (2) to measure changes in nurse knowledge pre to post educational session. None of the registered nurses in this study reported ever caring for a patient who had died with an ICD in place. Subsequently, their knowledge in end-of-life care surrounding this patient population significantly improved after the educational session (P.006). Knowing how to care for such patients as they are dying is imperative for nurses, especially because many ICD recipients have insufficient knowledge themselves and can benefit from education provided by nurses.

Aim To identify neonatal nurses' self-reported practices, knowledge and attitudes toward premature infant pain assessment and management. Method An exploratory cross sectional mixed methods survey. Findings Of the 127 surveys distributed, 86 were returned (68% response rate). Those with postgraduate education had higher knowledge and reported more positive attitudes. Comfort measures and analgesia for painful procedures were reported as used more often in term infants. Analgesia was not used for endotracheal intubation. This was attributed to non-prescribing of analgesia by doctors. Conclusion Nurses reported a positive attitude toward infant pain assessment and management but a low level of knowledge about premature infants' response to pain. The non-use of analgesia for painful procedures presents a formidable challenge to changing practice. Evidenced based strategies may overcome barriers.

Although new cancer therapies have changed the prognosis for some patients with advanced malignancies, the potential benefit for an individual patient remains difficult to predict. This uncertainty has impacted goals-of-care discussions for oncology patients during critical illness. Physicians need to have transparent discussions about end-of-life care options that explore different perspectives and acknowledge uncertainty. Considering a case of a new physician's objections to an established care plan that prioritizes comfort measures, we review physician practice variation, clinical momentum, and possible moral objections. We explore how to approach such conflict and discuss whether and when it is appropriate for physicians new to a case to challenge established goals of care.

Introduction: Transition to comfort measures only (CMO) is common in the neurocritical care unit, and close communication between interdisciplinary health-care teams is vital to a smooth transition. We developed and implemented a CMO huddle in an effort to reduce inconsistencies during the process of CMO transition. Methods: The CMO huddle was a multiphase quality improvement project in a neurocritical care unit of a level-1 trauma and comprehensive stroke center. Interdisciplinary critical care clinicians engaged in a huddle during CMO processes and participated in a pre- and postimplementation survey to examine the impact of CMO huddle on communication, missed opportunities, and improvement in knowledge. Results: Since the CMO implementation, a total of 131 patients underwent CMO transitions. After implementation of an interdisciplinary CMO huddle, 64.3% of neurocritical care nurses reported that they felt included and involved in CMO process compared to 28% before implementation ( P = .003); 87.9% of all neurocritical care clinicians reported that they felt comfortable participating in CMO discussions compared to 69.8% before ( P < .001); 57.4% of all neurocritical care clinicians reported that the CMO huddle improved communication among neurocritical care clinicians, 51.9% reported reduction in missed opportunities during CMO process, and 21.7% reported witnessing less-than-ideal CMO process compared to 80% before ( P < .001). Conclusions: Implementation of a multidisciplinary huddle in the neuro–intensive care unit before transition to CMO may improve clinician’s experience of the end-of-life process through enhanced nursing inclusion and involvement and organized communication with the neurocritical care team.

Sana Dastgheyb,1 Keith Fishlock,2 Constantine Daskalakis,1 Jami Kessel,3 Paul Rosen2 1Thomas Jefferson University, Philadelphia, PA, 2Nemours Children’s Health System, Wilmington, DE, 3Nationwide Children’s Hospital Columbus, OH, USA Introduction: Management of pediatric pain from medical procedures is of great importance for improving both patient care and experience. In this study, we investigated methods of managing acute pain in infants and children by studying the correlation between the number of attempts to complete painful procedures, given different comfort measures. Methods: The study is a retrospective review of 74,276 procedures performed at two pediatric hospitals in an integrated academic children’s health system between 2013 and 2016. We compared three comfort measures most frequently offered: positions of comfort (POC), distraction(DIST), and pharmacological (PHARM). These methods were compared in the setting of four procedures: peripheral intravenous (PIV) catheter insertion, gastrointestinal tube placement, incision procedures, and bladder catheterization. We used the number of attempts needed to complete a procedure as a measure of efficacy minimizing distressing experience in an acutely painful setting (single attempt vs repeat attempts). Results: Among younger children, DIST appears superior to the other two methods; it performs significantly better for three of the four procedures (PIV catheterization, incision wound, and urinary catheterization) among infants aged

Purpose The Comfort Theory proposes a systematic work approach to respond to patients' holistic needs. The usefulness of the Comfort Theory in the perioperative setting should be investigated. The aim of this study was to describe and analyze the nurse anesthetist's comfort measures in the preoperative context on the basis of the Comfort Theory Design Qualitative observational study Methods Semi-structured, clinical observation data collection in the preoperative context and deductive thematic analysis Findings The nurse anesthetist's comfort measures in the preoperative phase in the operating room department aim to ensure the patient's needs of relief, ease and transcendence in the physical, psycho-spiritual, environmental and socio-cultural contexts Conclusions The application of the Comfort Theory to daily work in the preoperative phase is of value for the nurse anesthetist in becoming more aware of the individual holistic needs of the patient and in this way adapting and initiating comfort measures and interventions.

Objetivo - Identificar las necesidades y las medidas de comodidad del paciente internado en cuidados intensivos. Material y Método - Las preguntas de la investigación son: ¿cuáles son las necesidades de comodidad del paciente internado en cuidados intensivos? Y¿cuáles las medidas que promueven comodidad al paciente internado en cuidados intensivos? Se procedió al análisis de las palabras clave del DeCS y MeSH en el ámbito de la comodidad del paciente mayor en cuidados intensivos. Búsqueda booleana en los motores de búsqueda de bases de datos: EBSCO, PubMed, B-ON, RCAAP, BVS, Cochrane Library, SciELO. Se obtuvo un total de 6488 artículos, constituyendo la muestra 10 artículos. Se procedió al análisis del contenido del corpus (corresponde a los cuidados de enfermería), del que se obtuvieron 2 categorías con un total de 55 unidades de registro. Resultados - La distribución de los datos ha sido hecha de acuerdo con los presupuestos teóricos de la Teoría de Kolcaba: en la categoría de las Necesidades de Comodidad (28 unidades de registro) - 28% son de contexto fisico, 14% ambiental, 56% psico-espiritual y 14% social; de las Medidas de Comodidad (27 unidades de registro) – 18% son tipo alivio, 56% tranquilidad y 26% transcendencia. Conclusión - Las necesidades de comodidad derivan esencialmente del contexto fisico y psico-espiritual y las medidas de comodidad más a menudo adoptadas son para el alivio y la tranquilidad. La disciplina de Enfermería es la que más preocupación demostra por los cuidados de comodidad. Aims – To identify comfort needs and measures of the patient admitted in intensive care units. Material and Method – The investigation questions are: wthat are the comfort needs of the patient admitted in intensive care and which measures should be undertaken to promote comfort to the patient admitted in intensive care units? It was carried out an analysis of the descriptors (keywords) in DeCS and MeSH within the scope of comfort care to elderly patient in intensive care units. Boolean research through data base searching engines: EBSCO, PubMed, B-ON, RCAAP, BVS, Cochrane Library, SciELO. It was obtained a 6488 article population of which 10 articles composed the sample. It was analysed the content of the corpus (corresponding to nursing care) allowing to obtain 2 categories totalizing 55 registration unities. Results – Data distribution was according to theoretical assumptions of Kolcaba Theory: in the category of Comfort Needs (28 registration unities) - 28% are of physical order, 14% environmental, 56% psycho-spiritual and 14% of social order; as far as Comfort Measures are concerned (27 registration unities) – 18% concern suffering relieve, 56% peaceful atmosphere and 26% transcendence. Conclusion – Comfort needs concern essentially physical and psycho-spiritual context and the comfort measures more frequently adopted are aim to relieve suffering and promote a peaceful atmosphere. Nursing disciplin is the one that shows more concern towards comfort care. Objetivo - Identificar as necessidades e as medidas de conforto do internado em cuidados intensivos. Material e Método - As questões de investigação são: quais as necessidades de conforto do doente internado em cuidados intensivos? e quais as medidas que promovem o conforto do doente internado em cuidados intensivos? Procedeu-se à análise dos descritores no DeCS e MeSH no âmbito do conforto do idoso nos cuidados intensivos. Pesquisa booleana nos motores de busca de bases de dados: EBSCO, PubMed, B-ON, RCAAP, BVS, Cochrane Library, SciELO. Obteve-se uma população de 6488 artigos, constituindo a amostra 10 artigos. Realizada análise de conteúdo ao corpus (corresponde aos cuidados enfermagem), do qual se obteve 2 categorias com um total de 55 unidades de registo. Resultados - A distribuição dos dados foi de acordo com os pressupostos teóricos da Teoria de Kolcaba: na categoria das Necessidades de Conforto (28 unidades registo) - 28% são do contexto físico, 14% do ambiental, 56% psico-espiritual e 14% do social; das Medidas de Conforto (27 unidades de registo) – 18% são do tipo alivio, 56% de tranquilidade e 26% transcendência. Conclusão - As necessidades de conforto decorrem essencialmente do contexto físico e psico-espiritual e as medidas de conforto mais frequentemente adotadas destinam-se ao alívio e à tranquilidade. A disciplina de Enfermagem é a que mais preocupação demonstra pelos cuidados de conforto.