How aggressive do you get with PCA in a comfort care setting.

On my unit, we care for many patients who are on comfort care, and more times than not, it includes a PCA drip, usually with continuous setting (instead of demand dose). The continuous order is usually a range that gives the nurse leeway to increase should the patient be in distress. The orders usually come with allowances for boluses as well.

My question is this. Say the order reads 1-5 mg/hr with 2-4 mg boluses Q1 for s/s of distress. Assuming you start at the 1mg/hr to start, where would you go from there? Let's say one hour later, you round and the patient has some mild distress and you want to increase the continuous...how much? Would you give a bolus?

I know every situation is different, and its hard to speak to hypothetical, but just give me an idea how much you adjust by.

Much thanks!
I would use the bolus first. If I need to use it frequently I would up the continuous and keep titrating by 1mg until the patient was comfortable. If you have a range don't be afraid to use it. Pain free is the goal.

Hypothetically speaking if JulesA is the patient please open the floodgates even if it hastens death.

I work Onc and we do a lot of comfort care. We use straight drips for comfort care, not PCA pumps. Our orders usually start at 1-5mg/hr and say titrate up to 10mg/hr for comfort. We titrate by 1mg/hr.

Thanks for the input. I know that these patients are going to pass regardless of what we do; however, it must happen in due time and euthanasia is not legal. I just see some of my coworkers adjusting by 2 or more mg/hour at the first sign of distress rather than using a bolus or a smaller increase per hour. I love hospice and comfort care, and I do not want anyone to suffer, but it is hard to know that the dose you last gave probably helped them over the line.