I was on my internal medicine clerkship on an inpatient general medicine service at a major academic medical center. It was another long day and our team, from the interns to the attending, was running low on energy. As we entered late afternoon, we received a page for the transfer of a new patient to our service. As the intern read aloud “CMO” — comfort measures only–the team breathed out a sigh of relief and dismissed the transfer from their list of priorities.
I was stunned. This was my first CMO patient, and I wasn’t sure why this was such a relief to the team. I soon came to learn what CMO meant for them. CMO meant no diagnostic work to do and no orders to put in, besides a morphine drip. CMO was synonymous with the unofficial permission to ignore the patient. No wonder the team was relieved.
When the patient arrived, she was unable to communicate any of her wishes easily due to severe dementia. She was immediately sedated with boluses of IV morphine every time she stirred in bed. I happened to step in her room as the morphine was wearing off. As I approached the side of her bed and whispered her name, her eyes shot open and she grabbed my wrist while repeating “God help me” over and over again. I called for the nurse and with another bolus of morphine, our patient drifted back to sleep.
I felt sick to my stomach. I did some research and was delighted to find detailed CMO guidelines for our center right on our website. I realized the team had either not known about or had ignored these guidelines. I quickly filled out the form to place the orders recommended by the guidelines. The form itself directed attention to many possible sources of discomfort for patients at the end of life that I had previously been unaware of. For this patient, it had been clear to me that she was uncomfortable. I did not realize until later that part of my discomfort was because she had been written for no food or water for over two days. That certainly didn’t sound like comfort measures to me!
Later that day, I felt tremendous relief as I helped the nurse administer the series of orders including eye drops for her bloodshot, dry eyes; lip balm for her dry, cracked lips; an anticholinergic to dry up her airway secretions that were making breathing difficult; a scheduled pain regimen with long-acting medicines to maximize comfort without pain flare-ups; and most of all, a clear liquid diet!
I learned so much from simply following the guidelines already in place. My team was unanimously positive about my proactive approach. Yet, I wondered why my actions were considered exceptional rather than expected.
After seeing my patient drift off to a peaceful sleep, no longer agitated and appearing much more comfortable, I contacted the author of the guidelines, a palliative care physician at my hospital. I spoke to the palliative care physician that same evening just upstairs from where my patient lay sleeping. She explained that although the guidelines were distributed to all caretakers, more often than not, they remained unused. In her many years of experience as a palliative care physician, she has observed that CMO is often translated practically as morphine drip only. She felt the hospital needed to improve the system for orders for these patients, and I volunteered to help out however I could. I went home late that evening wondering how I could help bring about an effective change.
I eventually met with the hospital’s chief quality officer and showed him an informal root cause analysis I had done my best to fill out. This was a valuable tool I had picked up through my work with the Institute for Healthcare Improvement and as a campus leader of their Open School chapter. He guided me through completing my analysis and agreed to give this area more attention once he saw data to support the extent of the problem.
I am currently working with the palliative care physician to compile data to demonstrate the standard of care for patients who are CMO. If we are able to collect this data, the hospital has promised to integrate the CMO guidelines into the electronic medical record. This integration would allow the system to detect a patient that is CMO and prompt their caregivers at the level of order entry to step through each evidence based guideline when placing their admission orders. This will require each area of comfort to be addressed and promote care to progress beyond a simple morphine drip.
This sort of improvement also represents a deeper underlying culture shift in medicine: one in which we no longer view CMO patients–patients who may be expected to die in the near future–as failures, but rather, as opportunities. It frightens me to think of all the patients who still suffer through their last hours when so many comforts are easily accessible, yet unknown. That night before I left the hospital, I remember seeing my patient eating a popsicle with an ever-so-slight smile tracing her lips. She died that night. I can only hope she was in more comfort and peace than when she arrived on our floor.