(360) Evaluation of a Nursing-Driven End-of-Life Protocol Targeting Pain and Discomfort

Introduction: Opioids are used to alleviate pain and dyspnea in end-of-life (EoL) care. The use of opioid intravenous pushes (IVP) versus intravenous continuous infusions (IVCI) is preferred due to the ability to rapidly achieve symptom control. Yale New Haven Hospital implemented a nursing-driven protocol in 2023 that emphasizes the use of bolus dose opioids before the escalation of IVCI for EoL patients in the medical intensive care unit (MICU). The purpose of this study is to assess adherence to the EoL opioid protocol.

Methods: This was a retrospective, single-center chart review within a 40-bed MICU. Adult patients were included if they were enrolled in the nursing-driven EoL pilot between October 1, 2023, and February 29, 2024. Patients were excluded if they were not admitted to the MICU, died within 60 minutes of becoming comfort measures only (CMO), were evaluated for brain death, or did not receive interventions through the order set. Data collected included demographic information, date and time of CMO order, and opioid infusion rates and bolus doses. The primary objective is to compare the average number of bolus doses prior to escalation of IVCI before and after protocol implementation.

Results: Eighty-nine patients were screened for inclusion and 46 met criteria. For the primary endpoint, the mean number of opioid boluses administered prior to escalation of IVCI rate for pre- and post-protocol implementation patients was 3 (2.6) versus 4 (4.3) boluses, respectively (p=0.08). The median morphine milliequivalents (MME) within 24 hours after becoming CMO for patients pre- and post-protocol implementation was 13.3 (4.9-28.9) and 50 (20.8-98.8) MME, respectively (p < 0.001). For the after-implementation population, the target Richmond Agitation-Sedation Scale (RASS) score was 0 (-1 to 0) with the highest RASS score being –2 (-4 to –1) and the lowest RASS score being –3 (-5 to –2). Dyspnea symptoms were documented in 33% of patients.

Conclusions: The nursing-driven EoL protocol showed no significant difference in bolus dose opioids compared to the previous provider-driven protocol. Patients had lower RASS scores than target and symptom documentation was inconsistent. This suggests an opportunity to streamline the protocol and enhance staff education on the importance of bolus dose opioids in EoL care.