Many patients today in End of Life (EOL) stage nowadays prefer having palliative rather than curative care. They or their near ones are knowledgeable about palliative and hospice care. They understand the differences such care and curative measures, as well as the effects of the two. There are a number of benefits to be derived out of palliative care. For the patient, this means relief from pain and the discomfort that is bound to follow due to the critical illness. However, such care is beneficial even for the family, as it provides a level of psychological support to everyone involved in this last stage of life of the patient.

The article Code Comfort by Beth Fahlberg brings to flight the various points that have to be kept in mind to ensure quick relief in end-of-life patients. It begins by giving an account of a specific patient, and the problems faced by her sister, who is also a professional nurse. The patient exhibits many symptoms, and the woman is frustrated by the low rate of response from the caregiving staff in the hospital. In her mind, she knows that the symptoms can be alleviated by using interventions provided in time. However, she is also aware of the various processes that come into play in a formal environment like a hospital (Fahlberg, 2015). The same interventions would have been given to her brother within two or three minutes had he been at home. However, this was delayed due to the sign-offs and other formalities that are necessary for a hospital.

The nursing interventions discussed in the article pertain to confronting and relieving breathlessness, pain, anxiety, and agitation. About these, Fahlberg acknowledges that specific institutional barriers do exist which prevent timely action on the part of the caregivers. For such cases, and especially for those who have specified that they should not be resuscitated, a new approach has been developed. This is called the Code Comfort approach, where a specific set of instructions for nurses is pre-shared, and which they can use on an immediate basis. Armed with this policy, nurses can function as a rapid response team. A Code Comfort team may also be charted out, and such a group will have not just nurses but also physicians, RTs, and chaplains (Fahlberg, 2015). The responsibility of the team extends not only to the relief of symptoms but to also provide support to the family of the patient. For a patient in end of life care, it is the reliving of symptoms and the associated pain and anxiety that is of primary importance, and Code Comfort provides just that.

Chronically ill patients face a multitude of uncomfortable symptoms and signs as death approaches. As an example, fluid retention caused by dyspnea in heart patients is very painful. Similarly, cancer patients go through a lot of pain. In other cases, these EOL symptoms may cover anxiety, delirium, fatigue, weakness, nausea, and agitation. At EOL stage, patients’ typical palliative care involves stopping of curative options and only continuing those that are able to relieve various symptoms. Thus, proactive intervention in palliative care can allow for better life quality, good sleep, low pain, and less fatigue. This helps in the sense of well being for the patient. Thus, even with a lack of aggressive care, intervention can assist in enhancing the quality of life and also extend survival.

The issue that is faced is with the timelines associated with palliative care. It is typically only used when the patient is very close to death. The reason why this happens is because of a lack of awareness on the part of both the healthcare providers and the patient that palliative care can be useful in easing symptoms. In their mind, it is the same as hospice or terminal care.  Moreover, it is also not possible for many patients to have access to specialists in the early onset of chronic illnesses. It was only in 2006 that palliative care was recognized by the National Quality Forum and quality guidelines for standardized palliative care were established (Morrison, 2013). This means that practitioners who have taken specific trainings are relatively few.

Code Comfort aims to identify suffering and provide immediate relief. Some processes are clearly defined and need quick and urgent teamwork to implement. For a critically ill patient who is unable to breathe and feels like she is suffocating, the experience can be incredibly terrifying. Typically, caregivers do not have a plan in place to intervene. A patient suffering from dyspnea, agitation and pain have many options available to them that are not very aggressive. Thus, it should be possible to provide these options through a pre-defined, pre-approved process, such as that of CPR.

Many patients choose a DNR status, and Code Comfort provides a guided response for them. It can manage pain, suffering and even emotional issues compassionately without forcing unwanted care on the patient. The respondents to a Code Comfort situation can include respiratory therapists, nurses, physicians, chaplains as well as any other professionals who can help in providing urgent relief to the patients’ symptoms, as well those of the family members.

Just as it is with CPR, it is teamwork that can relieve the suffering of an EOL patient quickly. Code Comfort protocols are guided by algorithms which assess and address pain, dyspnea, agitation, and other symptoms. For instance, in the case of a patient with severe dyspnea would have a process in place to be given morphine and higher levels of oxygen. Her head would be raised, and other means would be employed so as to reduce agitation and anxiety. IN this way, Code Comfort ensures that suffering is lessened. When the Code is active, nurses are present constantly, and other more qualified team members can be called in if the situation warrants it.

Different people have different understandings of what the terms DNR, no code, or full code mean. This leads to a further challenge in effective communicating between healthcare and legal professionals, and the general public. In my opinion, these terminologies should be discarded, and the focus should instead be on promoting a cultural change. This would involve a more accurate and precise development of care goals, and adequately communicating these goals. It would also entail developing plans about the responses regarding various interventions required in EOL cases. The mechanism that I would adopt for intervention would have a ordering and documentation for each level. These levels would be useful to provide guidelines to the staff about the goals of the care to be provided, as well as which interventions need to be used. These can be personalized as per the requirement of every patient. Different levels of requirement would involve different sets of people and healthcare professionals to be called upon. A higher level of requirement, such as level 3 and four would require professionals, and so on. The levels can be defined based on severity. All patients can be treated as level 1 upon admission until their diagnosis changes their status. The level 5 patients would be the ones who are in the EOL stage. The defined provision of interventions for this stage is built around patient comfort and palliation, and the aim to provide dignity and comfort. These patients would be on DNR status, and the focus of intervention would be to lowering of symptoms rather than achieving cure. Implementing this level would also imply that the professionals responsible are aware that a DNR status does not say anything about the patients’ preference for other treatment. One of the crucial developments in treatment goals for patients has been the POLST Paradigm, which stands for Physician Orders for Life-Sustaining Treatment. It is based upon the pre-requisite that not all patients will choose comfort measures in isolation (Sabatino & Karp, 2011). For Code Comfort to be implemented at level 5, it is necessary to hold discussions with the patients and the families regarding the goal of the care. The Evaluation of the success of this level based system would involve a study of the care provided, the outcomes achieved, and mapping with the results expected. This would include identifying characteristics in the care program which can be measured.

Front line staff in medicine can be empowered by Code Comfort. This becomes even more important when one considers the criticality behind preventing an acute symptom crisis. Moreover, the Code lessens the perceived stigma associated with DNR. Rather than focusing on what won’t be done, it shifts the direction of thought to what will be done. The critical point of the Code is that it removes the issue of patients and families having to choose between an all or nothing approach, and relives suffering.

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