The atmosphere of ICU is extreme and fast-paced, with the ultimate goal of restoring health. Sometimes patients cannot be revived, and death is imminent. Once all curative measures have been utilized, lifesaving care changes to providing comfort care, also known as palliative care and/or end-of-life care. During this stressful experience, many families of patients in critical care choose to remain at the bedside until the patient dies. Bedside nurses are trained to save lives and find it challenging to provide support to friends and family experiencing imminent death of a loved one. When all attempts to save a life have been extended and death occurs, both families and nurses suffer.
In 1998, Institute of Medicine (IOM) defines a good death as “one that is free from avoidable distress and suffering for patients, families, and caregivers; in general accord with patients' and families' wishes; and reasonably consistent with clinical, cultural, and ethical standards.”1 When addressing comfort, it is important to recognize the relationship between the physical experience and emotions, cognition, and spirituality. As families come together in the hospital setting due to the critical illness of a loved one, the environment can be extremely stressful for the family especially given a poor prognosis.2
The RN-to-BSN students at a state college in central Florida are challenged to implement a QI project, and this article describes the steps taken to implement a comfort care cart. The development of a cart that has items such as refreshments, resource material, and personal belongings provides support for families during near-death transitions. Using the cart, critical care nurses can intentionally create a space that is mindful of the specific needs families and caregivers have as death approaches. The comfort cart can provide a sense of a security that enhances the caring experience.
THEORY AND RECOMMENDATIONS
Dr Katharine Kolcaba synthesized her theory of comfort into 3 types: relief, ease, and transcendence. She believed there are 4 contexts in which comfort can be experienced: physical, psychospiritual, sociocultural, and environmental. When considering the management of comfort and comfort care, nurses should consider “interventions, comforting actions, goals of enhanced comfort, and selecting appropriate health-seeking behaviors by patients, families, and nurses.”3 The theory of comfort is patient-centered care and seeks to provide comfort as foundational to family recovery.4 In addition to the work of Kolcaba, the comfort care cart supports the recommendations of the 2014 consensus report that was developed by a committee of experts from the IOM.4
Dying in America: A Report
In 2014, a consensus report was developed by a committee of experts from the IOM.4Dying in America: Improving Quality and Honoring Individual Preferences Near the End of Life details specific burdens that health care workers face today and reports key findings and recommendations. The IOM details a comprehensive report of findings that affect the quality of palliative care and describes 5 recommendations for improvement. The rationale for the comfort care cart followed the recommendations in the Dying in America report. For the purposes of this article, findings and recommendations were summarized for application of palliative care in the ICU (Table 1).
DESIGNING A QUALITY IMPROVEMENT PROJECT
The project leader and staff nurses recognized a need to improve the transition of care from curative to comfort care. The nurses were motivated and interested to see if the comfort cart improved the family experience. Once the decision to cease lifesaving interventions is agreed upon, a comfort cart will allow bedside nurses to provide basic provisions to the family. To introduce this project, the project leader met with staff nurses and leadership within the unit and then built a QI project to develop and evaluate the implementation of a comfort cart in the ICU.
The QI project was inspired through coursework and guided by improvement science and education and tools from the Institute for Healthcare.5 The IHI Open School is an online educational community that provides essential training and tools to help health care providers deliver exceptional and safe care.5 The pilot project used the Plan-Do-Study-Act cycle, an IHI process, to implement a single aim: the creation of a comfort care cart in the ICU. The cycle consists of creating a plan to test the change (Plan), conducting the test (Do), observing and learning from outcomes (Study), and making modifications to the test (Act). The cycle is repeated with the new changes, if warranted. During the planning phase, a review of the databases for literature supporting comfort carts with that specific wording found minimal results. The field of palliation is robust with information; however, in order to find supporting articles, the conceptual items offered in the cart were researched individually as means to support grieving families. Additionally, the project leader realized that the term “comfort cart,” or other descriptions of support measures, may not be commonly defined as keywords.
The project leader was a practicing trauma ICU nurse and noted a clinical problem. Anecdotally, she found that other nurses felt ill-prepared to provide comfort for families once goals of care shifted from curative to comfort-driven. During staff discussions, nurses agreed that these inadequacies left them feeling frustrated, and family's emotional and physical needs unmet.
Planning the pilot project began with conversations between unit leadership and the project leader to organize implementation and usage of the cart. Once approved as a pilot project, a repurposed 3-drawer dresser was painted, and locking wheels installed (Figure). To help nurses feel more engaged with the project, the project leader held several informal conversations with staff about what to include on the cart. The contents included snacks, supportive reading materials, and comfort items such as a blanket and tissues. Nurses agreed that the cart serves as a visual reminder for the staff that the patient was to receive comfort measures, which extends to the care of the family, which included basic nutrition and comforts of home into the clinical environment for the families. Nursing leadership in the medical ICU (MICU) approved implementation of the cart. With stakeholder's approval, the project leader funded the project independently. Prior to full implementation, the author had multiple conversations with supportive departments, food services, engineering, management, palliative care, and risk management. During a nursing staff meeting, which consisted of unit manager, team leaders, bedside nurses, and patient care assistants, the project was explained as a QI initiative. Implementation of the cart was adequately described, and each item in the drawers was explained.
The cart was in the charge nurse office so that it remained visible to the nursing team and readily available for implementation. Initially, after the first 2 weeks, interviews with staff nurses revealed a reluctancy to use the cart out of fear of doing it wrong. The project leader met with 1 nurse who agreed to use the cart with 1 patient and then provide feedback on its use. The small-scale implementation follows the QI project PDSA method, which encourages small tests of change rather than full unit implementation. A meeting was held with the implementing nurse, in which teaching points were reinforced and feedback was provided for which family was suitable for the cart. Also, encouragement and continued support were available to the nurse by the project leader.
After the first cart implementation, subjective data gathered by conversations between the implementing nurse and the project leader revealed several findings. The nurse reported that the family felt consoled with the thoughtfulness of the nursing team and valued despite the poor prognosis of their family member. Once implemented, the nursing team discussed concern about deploying the cart to 1 family when there were often multiple patients who would benefit from use of the cart. A consensus from the nursing team revealed that moving the cart to a more centralized location would allow more than 1 family to use the cart at the same time. Once usage of the cart was expanded, staff stated that family members felt well-cared for by the nursing team when offered nourishment from the cart. Family members were relieved that nutrition was offered so they could remain at the bedside.
After collaborating with the nurses in MICU to better address the needs of multiple families, adjustment to the plan was developed. Instead of 1 room and 1 patient/family deployment, the decision to move the cart to a family consult room was agreed upon. This would allow the cart to be used by multiple families as the consult room is used as a respite space during final transitions. In following with the PDSA format, moving the cart to the family consult room would begin a second cycle of the process. The project could repeat each phase and move forward with changes, policies, and formatting the cart to the specific needs of the unit or floor. This adaptation was informed and supported by the work of Dreher6 suggesting specific details transforming the ICU or adjacent room into a home-like atmosphere.
In addition to the IOM report, the American Association of Critical-Care Nurses has designated a healing environment as a priority,7 and a detail-oriented focus on the sensory experience of the patient, family, and nurses can change the space from ICU functionality to one of connection and purpose.8 Our design and implementation were consistent with these goals. The preparation of the room should be organized with grace and personalized to meet the needs of the patient and family unit7:
- Scented battery-operated candles are to be placed around the room to alter the mood from harsh lighting to a sense of peace and safety.7
- Extra chairs are brought in for additional seating.6
- The bedding is changed to a colorful quilt and pillow sham or colorful towel if oral secretions are copious.6
- The bedside monitor is changed to a comfort mode setting and silenced within the room.6
- A compact disc player is provided with a variety of music choices.6
- A drape is provided to cover intravenous poles.6
- The room should be devoid of clutter and extra materials.7
- Aromatherapy is offered to manage patient odors.7
- The family is encouraged to bring in sacred objects or family mementos.7
The result of this transformation is a tranquil, peaceful environment that embraces all who enter including the members of the health care team.6 Nurses have the power to leave the family with a lasting image of their family member, an image that should bear dignity and respect.
To support families, the Journal of the American Osteopathic Association recognizes the exhaustion of grief and that providing snacks and drinks is a means of diversion from the minute-by-minute progression of dying.9 Dreher,6 Bruce,9 and Beckstrand et al10 discuss the need to have beverages and snacks as families will forget to eat during this time. Offering poems, meditations, religious and spiritual readings, and a Bible inspire peace during the final moments of a patient's life.11 Encouraging families to participate in a shave or bath can make the evolution from life to death one of harmony and comfort despite being in the highly technical settings of an ICU.12 Additionally, the anointing of oil and a liturgy of nondenominational words given to families as a means to say good-bye assist in the transition to leaving their loved one.12 The anointing of oil can be conducted by the nurse or religious leaders or a private moment between the family and the patient. The liturgy of words and oil are provided in the cart. By integrating the bathing and honoring practice into the nurses' role, the dignity of respecting the deceased body can provide valued support to newly grieving families.
The cart designed for this QI project utilized the top space as a staging area for 3 carafes: cold water, hot water for tea, and hot coffee. The first drawer contained all the items needed for the drinks: cups, cream, sugar, spoons, napkins, and several varieties of teas. Additionally, placed on the top of the cart was a small basket of fresh fruits and light snacks such as granola bars. There was a small jar of mints and a box of nonhospital tissues. The second drawer contained items used for providing a shave, lotion and oils for massage, a liturgy of nondenominational words12 (Table 2), and 3 scented battery-operated candles. A script of words is provided for family and/or staff to recite at the bedside with family or caregivers. This gives the opportunity for family to have a bedside ceremony honoring the life and body of the patient. The third drawer contained a small quilt and literature for reading: a Bible, brochures for grief support, and inspirational texts for the families waiting. Additionally, reading materials or specific care items could be added at family members' request.
Implementing a Care Cart
The QI project piloted a comfort cart in the MICU of a large central Florida hospital. Guided by the PDSA framework, the nursing staff found that the comfort cart created a positive outcome of improved staff and family satisfaction with end-of-life care. The project stimulated new ideas and future recommendations and suggestions to improve palliative care in the ICU. Stakeholder buy-in is an essential element to the outcome of the comfort cart. Project leader also found that bedside critical care nurses are vital for successful deployment of the cart. Nurses working to implement a similar project should be the primary decision makers of the cart. Given that the comfort cart does not contain medications and does not need a doctor's order, nurses have autonomy to utilize the cart with a family unit. Prior to the introducing the cart to family, decisions regarding do-not-resuscitate, comfort measure orders, and a change in care plan should be discussed beforehand. Following the steps outlined in the PDSA, a nurse-driven initiative promotes self-efficacy and independence for nurses at the bedside.
The use of a comfort cart has tremendous utility in many areas of nursing outside of the ICU. The cart can be used in pediatrics, medical-surgical, oncology, labor and delivery and postpartum floors, hospice centers within the hospital, and geriatric units. One advantage of the cart is its availability to any nurse in any field of nursing in which the goals of the cart are applicable to the needs of the patient and family.
Although it may be difficult to connect with the family during the initial time period after death, a family survey could provide vital information for the use of future carts, contents, and overall comfort level. A variety of options are available for the physical design of the cart. Other comfort carts were developed from traditional 3-tiered office carts, coffee and tea carts, an armoire, a portable kitchen island,13 and an old code cart.14 Future carts that are designed to be wheeled from room to room by nursing staff will greatly reduce the potential of cross-contamination with patients who are on isolation precautions versus families who are not on isolation (Table 3).
Since initiating the comfort care cart, another student chose to offer comfort in a more compact manner at a small facility in central Florida. Using the same PDSA model for change, this bedside nurse created a comfort kit. Contained in the portable version of the kit were a Bible, paper and pen, tissues, an uplifting book, pamphlet of local community grief support, and simple snacks. There is also a condolence card that is signed by the caregivers and sent to families once the patient dies.
Despite advancing technologies in health care, 1 of 5 patients will die in the ICU.15 When curative measures are terminated, transformation of sterile hospital environment to a place of serenity and peace can impact both family and caregivers, thus providing a long-lasting image of dignity and respect. The comfort cart in the ICU fosters that transformation, allowing nurses to extend a palliative plan of care to the family in a tangible way. Nurses are uniquely positioned to bring clinical change to the bedside through improvement in science models, such as the IHI's Open School and the PDSA model.5 Although the implementation of a comfort cart needs interdisciplinary collaboration, a nurse champion is vital for the overall success and continuation of the cart.
The Institute for Healthcare Improvement Open School
The authors acknowledge Lisa Davison, BSN, RN, at Bartow Regional Medical Center for her work implementing a comfort care kit. The authors also acknowledge Lakeland Regional Health and Baycare for empowering their nurses to implement PDSA projects while in Capstone, their final course in the RN-to-BSN program at Polk State College. Dr Mimi Jenko of Greenville Technical College, South Carolina, for her contributions in editing and support during the process of this manuscript.
1. Emanuel EJ, Emanuel LL. The promise of a good death. Lancet
. 1998;351. doi:10.1016/s0140-6736(98)90329-4.
2. Magpantay-Monroe ER. Exploring the emotional intelligence of Florence Nightingale. Asia Pac J Oncol Nurs
. 2015;2(2):107–111. doi:10.4103/2347-5625.157587.
3. Alligood M, Dowd T. Theory of comfort. In: Nursing Theorist and Their Work
. 8th ed. St Louis, MO: Elsevier; 2014:657–671.
4. Dying in America: Improving Quality and Honoring Individual Preferences Near the End of Life
. Published October 19, 2018. Accessed January 16, 2020.
5. Improving health and health care worldwide. Institute for Healthcare Improvement. http://www.ihi.org/
. Accessed January 16, 2020.
6. Dreher BS. All the comforts of home: transformation to a comfort environment in critical care. Crit Care Nurse
. 2017;37(1):78–80. doi:10.4037/ccn2017350.
7. Fournier AL. Creating a sacred space in the intensive care unit at the end of life. Dimens Crit Care Nurs
. 2017;36(2):110–115. doi:10.1097/dcc.0000000000000231.
8. Anderson M. Sacred Dying: Creating Rituals for Embracing the End of Life
. 2nd ed. New York, NY: Marlowe & Co; 2003.
9. Bruce CA. Helping patients, families, caregivers, and physicians in the grieving process. J Am Osteopath Assoc
. 2007;107(12 suppl 7):ES33–ES40.
10. Beckstrand RL, Callister LC, Kirchhoff KT. Providing a “good death”: critical care nurses' suggestions for improving end-of-life care. Am J Crit Care
11. Wiegand DL, Grant MS, Cheon J, Gergis MA. Family-centered end-of-life care in the ICU. J Gerontol Nurs
. 2013;39(8):60–68. doi:10.3928/00989134-20130530-04.
12. Rodgers D, Calmes B, Grotts J. Nursing care at the time of death: a bathing and honoring practice. Oncol Nurs Forum
. 2016;43(3):363–371. doi:10.1188/16.onf.363-371.
13. Brown S. From code cart to comfort cart in the ICU. Health Management. https://healthmanagement.org/c/icu/post/from-code-cart-to-comfort-cart-in-the-icu
. Published May 23, 2018. Accessed January 16, 2020.
14. Aust S. Mader's carts provide comfort to families. The Garden City Telegram. https://www.gctelegram.com/86e3e437-7ac6-5c6d-9bb3-9f5075791753.html
. Published 2016. Accessed January 15, 2020.
15. The Dartmouth Atlas of Health Care. ICU/CCU Days per Decedent During the Last Six Months of Life, per HRR
. Published 2015. https://www.dartmouthatlas.org/interactive-apps/end-of-life-care/
. Accessed January 12 2020.