The Comfort Care Concept at End of Life

Introduction End of life is a concept that is often ignored despite the fact that everyone will die some day. It is because death is a part of life that people are familiar with comfort care given at the end of life. Comfort care is offered when someone is dying, and when the end is predictable. Comfort care is an essential part of nursing care at the end of life. It is care that helps or soothes a person who is dying. The goal is to prevent or relieve suffering as much as possible while respecting the dying person’s wishes (NIH, 2012). The goal of comfort care in nursing is the immediate state of being strengthened by having the needs for relief, ease, and transcendence addressed in the four contexts of holistic human experience: physical, psychospiritual, sociocultural, and environmental (Kolcaba, 2010). I have worked in the oncology field of nursing for 16 years and have seen several patients go through the end-of-life process. I have seen the better outcome of the dyeing process take place, this is when all four holistic human aspects are met, but sadly I have also seen a few complete the process without having one or more of the holistic context met. I must emphasize that delivering exceptional nursing comfort care to the patients who are in their final days or even hours prior to death, is just as vitally important as delivering critical care to the acutely or critically ill patients. The purpose of this paper is to evaluate and describe the concept of comfort care at end-of-life, thus allowing me to gain more knowledge and incorporate it into my own nursing practice.
Literature
Comfort is a term that has a holistic, complex and a significant historical association with nursing since the time of Nightingale. The origin of comfort is confortare, meaning to strengthen greatly (Kolcaba, 2010). This strengthening characteristic associated with enhanced comfort is especially intriguing to the goals of all nursing spectrums. According to Kolcaba (2003), comfort is defined as "the immediate state of being strengthened through having the human needs for relief, ease, and transcendence addressed" (2003, p. 251). The three types of comfort were derived through Kolcaba's research while developing her concept analysis of comfort. Relief is the state of having a discomfort mitigated or alleviated. Ease is the absence of specific discomforts. Lastly, transcendence is the ability to "rise above" discomforts when they cannot be eradicated or avoided. The three types of comfort can occur in four contexts of experience: physical, psychospiritual, sociocultural, and environmental. Later, Kolcaba continued her work on the comfort theory by developing a broader theory for comfort and a taxonomic structure. This structure was developed as a guide for assessment, measurement and evaluation of patient comfort. In this context, the physical are needs that pertain to bodily sensations; the psychospiritual is pertaining to internal awareness of self, including esteem, concept, sexuality, and meaning in one's life and one's relationship to a higher order or being; the sociocultural which pertaining to interpersonal, family, and social relationships; and lastly, the environmental is pertaining to the external surroundings, conditions, and influences; (Kolcaba, 2003). Indeed, the work of Katharine Kolcaba, RN, MSN continues to be of vital use till this day in nursing. There are other nursing theories which discuss comfort care. For example, Sr Callista Roy built her theory of adaptation around the nurse who helps the patient adapt to four categories of needs physiological, self-concept, role-function, and interdependence (Roy & Roberts 1981). The nurse was to employ traditional comfort measures to achieve comfort in the physiological mode. If one of the basic physiological needs was compromised, the nurse assessed the problem and provided comfort, thereby relieving the discomforts of physiological compromise. Dr. Jean Watson developed a theory in which she stated that a patient's environment was critical for his or her mental and physical well-being. Therefore, the nurse provided comfort through environmental interventions. In her theory, Watson used the term "comfort measures" synonymously with "interventions" which were based on a moral, ethical, philosophical foundation of love and value (Watson, 1979). In Dr. Josephine Paterson's comfort theory, which has characteristics of Humanistic Nursing, Paterson called comfort a construct that communicated "the nature or experience of nursing". She believed that comfort was an "umbrella under which all the other terms such as growth, health, freedom, and openness could be sheltered" (Paterson & Zderad 1988). Paterson was a psychiatric nurse, therefore she defined comfort from a mental perspective rather than from a physical one. She believed that mental discomforts could often lead to physical discomforts. Paterson was using comfort as a stable state but with existential properties of transcendence into freedom from discomfort. These theories all speak of comfort as a requirement for a successful and satisfying patient outcome, yet none fully define the meaning of comfort. Leaving the definition of comfort to be defined by the patient's situation and by the nurse's perception.
Logical Adequacy in the comfort care concept Placing the concept and goal of comfort within a framework for nursing provides nurses with rationale for enhancing patient comfort. Prior to presenting the theory, it is important to understand the authors' premises as applied to nursing. Theories from authors such as Roy, Watson and Paterson have premises such as: Comfort is a desirable, positive, holistic outcome that is germane to the discipline of nursing; patients strive to have their basic comfort needs met; when discomforts such as environmental cannot be prevented, patients can be assisted to experience partial or complete transcendence through comfort interventions that convey hope, success, caring, and support; lastly, when nurses apply the Comfort Theory, they efficiently consider and minister in a caring way to the uniqueness and complexity of each whole patient during their end-of-life. Thus, the concept offers an efficient way to deliver a pattern of care and communicate to the nursing team the interventions that work for the patient. Also, the theoretical structure of the comfort theory has real potential to direct the work and thinking of all healthcare providers (March, A. & McCormack, D., 2009).
Gaps and Inconsistencies in the comfort care concept The Theory of Comfort is a mid-range theory for nursing practice and research. It is a mid-range theory because of the limited number of concepts and propositions, low level of abstraction, and ease of application to actual practice (Kolcaba, 2013). In order to use the theory, three steps are required: (a) understanding the technical definition of comfort and its origins, (b) understanding the relationships (propositions) between the general concepts entailed in the theory, and (c) relating the general concepts to specific patient problems and/or settings (Kolcaba, 2013). The National Institutes of Health (NIH) State-of-the-Science Conference Statement on Improving End-of-Life Care states that there has been a lack of definitional clarity related to several concepts and terms which included end of life and transition of care. This lack of clear definitions for these terms represents a barrier to research on comfort care (NIH, 2004). Actively dying has not been well defined. One definition described it in terms of the last hours or days of life, and the other discussed the presence of unique signs and symptoms preceding death. There is a paucity of studies on the signs of impending death. Further studies are needed to examine specific signs that may signal that the patient is actively dying and to allow clinicians to educate family members and make appropriate recommendations toward maximizing comfort and minimizing aggressive end-of-life measures (Hwang, p. 835-840). Lastly, the word comfort itself lacks precise meaning in nursing. Proper studies need to be conducted which would thoroughly analyze the semantics and extension of the term "comfort" in order to clarify its use in nursing practice, theory and research.
Recent Developments After Kolcaba finalized her concept analysis on the Theory of Comfort, she later modified it with some changes based on her findings throughout the years. Kolcaba published a final version in 2013, in which she concludes that comfort is viewed as an outcome of care that can promote or facilitate health-seeking behaviors (McEwen & Wills, p. 244). It is posited that increasing comfort can enhance health-seeking behaviors. One proposition notes that "if enhanced comfort is achieved, patients, family members and/or nurses are strengthened to engage in health-seeking behaviors, which further enhanced comfort" (Kolcaba, 2013, p.197). Major concepts described in the theory of comfort include such others not mentioned previously in this paper such as institutional integrity and intervening variables. These major concept derivations have led to recent developments and research in the nursing profession.
Summary
As I learned in reference of several theories of comfort, I learned that all encouraged nurses to think more deeply about rather or not their patient is comfortable. These theories provide simple steps to ensure comfort is being delivered and they are all based on a very practical concept, that of all patients feeling better when they are comfortable. Comfort care at end-of-life is important for the facilitation of a peaceful death, which sometimes is the most realistic outcome for a patient. This realization of outcome may come slowly to nurses, other care providers, and families. During the dyeing process, hope can still be maintained, but gradually the focus for hope changes to the possibility of a "good death". Kolcaba and Fisher (1996) cited Dozor and Addison (1992) in defining a good death as, "being meaningful for all, a death that ends well for patient, health care workers, and family. It is a time to say goodbye to each other and to the mortal life of the patient and to find meaning in that life" (p. 75). Comfort care is a positive outcome that theoretically empowers patients and their families. The theoretical structure of the comfort theory has real potential to direct the work and thinking of all healthcare providers (March, A. & McCormack, D., 2009).

References:
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Hwang, I.C., Ahn, H.I, Park, S.M., Shim, J.Y., Kim, K. K. Clinical changes in terminally ill cancer patients and death within 48 h: when should we refer patients to a separate room? Support Care Cancer, 21 (2013), pp. 835–840
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