When something goes wrong with a patient or a med

Charting each comfort care dose when the doses keep climbing

Climbing PRN doses at the end of life read one way at the bedside and another a year later. Chart the symptom, the order, the response.

8 min read built on 3 full opinions updated 2026-10-09

Written by a med-surg RN, ten years, day shift. Why there is no name on it · How this guide is made

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Your patient is actively dying and on comfort measures. You're giving PRN morphine and lorazepam every hour, sometimes more often, and the doses keep going up. Each of those doses gets its own short note: what you saw, what you gave and under which order, and what changed after. Picture someone reading the chart later who wasn't in the room. They should see a symptom, a dose, a response. Over and over. Nothing else.

Key points

  • Before each dose, chart the symptom in terms another clinician could observe: respiratory rate, accessory muscle use, grimace, moaning, restlessness, a scale score.
  • Name the order: drug, dose, route, time, and the PRN parameter the patient met. If the dose goes up, write who ordered the increase and when.
  • Reassess at a set time and chart what you found. That includes the times the dose did little or nothing.
  • Keep the goals of care easy to find: code status, decision maker, and the conversation that set comfort care.
  • When the patient dies, chart the last dose time and your last assessment as plain facts. Don't hide the timing. Don't guess at a cause.

What to write

How it often gets charted How it reads better
2200 morphine 4 mg IV for comfort.2200 RR 34, accessory muscle use, grimacing, moaning with turns. Morphine 4 mg IV per PRN order for dyspnea RR >24. 2215 RR 24, no accessory use, face relaxed.
2300 more morphine given, pt still SOB.2300 RR back to 32, restless, pulling at gown. Little response to 4 mg at 2200 (eased for about 40 min). Dr. Lee notified 2245, new order morphine 6 mg IV q1h PRN. 6 mg given 2300. 2320 RR 22, settled, opens eyes to voice.
Ativan given, pt resting.0015 picking at lines, moaning, unable to settle with repositioning and dim lights. Lorazepam 2 mg IV per PRN order for agitation. 0045 lying quietly, RR 18, no grimace, rouses briefly to touch.
Pt sedated, family at bedside.0100 RR 14, regular, no grimace or restlessness. Not rousing to voice. Daughter (HCPOA) at bedside, updated on breathing pattern and plan to continue current PRN orders.
Pt passed peacefully after meds.0140 no respirations, no apical pulse x 1 min. Last morphine 6 mg IV at 2300, last lorazepam 2 mg IV at 0015. 0100 assessment as above. Dr. Lee notified 0145. Family present.
Gave 20 mg as ordered.New order 20 mg IV x1 from Dr. Ray. Pt has received 2 mg doses today. Held, called Dr. Ray 1010 to confirm dose and route. Order changed to 4 mg IV. 4 mg given 1020.

Every entry in the right column has the same four things: an observable trigger, the order the dose fell under, a timed reassessment, and the name of whoever changed the plan.

Template

Each PRN dose

[TIME] Assessment before dose: RR [NUMBER], [REGULAR / IRREGULAR / ACCESSORY MUSCLE USE].
Signs: [GRIMACE / MOANING / RESTLESSNESS / PULLING AT LINES / OTHER OBSERVED SIGN].
[SCALE NAME] score [SCORE], if used on this unit.
Nonmedication measures tried: [REPOSITIONING / ORAL CARE / FAN / NONE, WHY].
Given: [DRUG] [DOSE] [ROUTE] at [TIME] per PRN order for [INDICATION AND PARAMETER IN THE ORDER].
Reassessed [TIME]: RR [NUMBER], [SIGNS PRESENT OR ABSENT], [RESPONSE TO VOICE / TOUCH].
Response: [RELIEVED / PARTLY RELIEVED, LASTED ABOUT [MINUTES] / NO CHANGE].
[FAMILY MEMBER, RELATIONSHIP] at bedside, updated on [WHAT WAS DISCUSSED].

When the dose goes up or a new order comes in

[TIME] Symptoms not controlled on current orders: [OBSERVED SIGNS], last dose [DRUG DOSE ROUTE] at [TIME] with [RESPONSE].
[PROVIDER NAME] notified at [TIME] by [PHONE / IN PERSON].
New order: [DRUG] [DOSE] [ROUTE] [FREQUENCY] PRN for [INDICATION AND PARAMETER].
Order read back and confirmed with [PROVIDER NAME] at [TIME].
First dose under new order given at [TIME]. Reassessed [TIME]: [FINDINGS].

When an order does not fit the recent doses

[TIME] Order received for [DRUG] [DOSE] [ROUTE] from [PROVIDER NAME].
Pt doses over past [HOURS]: [DRUG DOSE ROUTE TIMES].
Dose held pending clarification. Called [PROVIDER NAME] at [TIME] to confirm dose and route.
Outcome: [ORDER CONFIRMED AS WRITTEN / ORDER CHANGED TO [NEW ORDER]].
[CHARGE NURSE / ATTENDING NAME] informed at [TIME].
Given [DRUG] [DOSE] [ROUTE] at [TIME]. Reassessed [TIME]: [FINDINGS].

Goals of care, once per shift or on any change

[DATE] [TIME] Code status: [DNR / DNI / COMFORT MEASURES ONLY], per order dated [DATE].
Decision maker: [NAME, RELATIONSHIP, HCPOA / SURROGATE], phone [NUMBER].
Advance directive located in chart under [SECTION], reviewed [DATE].
Plan of care discussed with [NAME] on [DATE] by [PROVIDER NAME]: [GOALS AS STATED IN PROVIDER NOTE].

Death note

[TIME] No spontaneous respirations, no apical pulse for [DURATION], pupils [FINDING].
Last doses: [DRUG DOSE ROUTE] at [TIME]; [DRUG DOSE ROUTE] at [TIME].
Last assessment before death at [TIME]: RR [NUMBER], [OBSERVED SIGNS].
Present: [NAMES AND RELATIONSHIP / NO ONE PRESENT].
[PROVIDER NAME] notified at [TIME]. Time of death pronounced at [TIME] by [NAME].
[CHAPLAIN / SOCIAL WORK / HOSPICE] notified at [TIME].

Words to avoid

Word or phrase Why it hurts Use instead
for comfort (alone)No symptom, so nobody can check the reason for the doseThe sign you saw: RR 32, accessory muscle use
to help him pass, to let her goMakes death sound like the purpose of the doseLeave it out. Chart the symptom and the dose
peaceful after dose, passed shortly after medsImplies the dose caused the deathLast dose time, last assessment, time of death, each on its own line
extra dose, a little moreSounds like dosing off-orderMorphine 6 mg IV per PRN order [X]
titrated to comfort (no measure)Doesn't say what you titrated againsttitrated to RR under 24 and no grimace
sedated, knocked outSounds like sedation was the goalWhat you saw: not rousing to voice, RR 14 regular
not intended to hasten deathReads like a defense written in advance. The indication and the reassessment already show intentThe symptom, the order, the reassessment
family wanted moreSuggests the family set the doseDaughter reports pt grimacing. Assessed: RR 30, grimace. PRN given per order.

A climbing dose with no reason or result

The typical note shows the dose and that's it:

2200 morphine 4 mg IV given for comfort. 2300 morphine 6 mg IV given for comfort. 0015 lorazepam 2 mg IV given. Pt resting. 0140 pt expired.

At the bedside it all made sense. You saw air hunger, gave a dose, it eased, it came back. A reviewer reading the chart a year later sees something else: a dose ladder that climbs and ends in a death. For comfort describes nothing they can check. Resting could mean comfortable. It could also mean oversedated. No line ties a dose to a symptom, and no line shows you adjusted to what the patient was doing.

The note records the action and skips the reason and the result. The reason is the symptom you saw. The result is the reassessment. Those two are what make a climbing dose read as titration. Leave them out and the reader fills the gap with whatever story they already believe.

Second problem: an order that doesn't fit what came before. Say the dose jumps far past what the patient has been getting, and the note doesn't show who ordered it or why. Now the nurse who gave it shares the scrutiny with the prescriber.

Bottom line

Every dose needs three things in the note: what you saw, what you gave and under which order, and what changed when you went back to check.

Official guidance

In court, 2006–2016

What happened in 3 court cases

Pruette v. Ungarino: Court of Appeals of Georgia, 2014. A 79-year-old woman with end-stage COPD went into respiratory distress. Her attending talked with the family and her pulmonologist, then ordered 2 mg of morphine as needed. Another physician, who had never treated her, read the chart. Without speaking to the attending, the nurse, or the family, that physician "changed Vinson’s chart to order that she be given 20 milligrams of morphine in a single dose." About 40 minutes after the code, the nurse gave the 20 mg. "Vinson soon lost consciousness and died approximately three hours later." The family sued and claimed that the nurse giving the dose was by itself a breach of the nursing standard of care. The first jury found against both the physician and the hospital. On retrial, the jury cleared the physician and found against the hospital, the nurse's employer. The appeals in this opinion turned on procedure; the hospital's own appeal was decided in the same consolidated ruling. For charting, the lesson is the tenfold jump from the attending's plan. When an order doesn't fit the patient's recent doses or the plan the family agreed to, clarify it with the prescriber before you give it. Then chart that you did.

Grotti v. Belo Corp.: Court of Appeals of Texas, 2006. This is a libel case. A physician sued a TV station over its reports on two patient deaths. The court held the broadcasts substantially true because they accurately reported allegations and investigations by others. It made no finding that anyone was euthanized with morphine. So why read it as a nurse? Because it shows who ended up reading one end-of-life morphine chart. The medical examiner first recorded "acute morphine intoxication by accident" and later reclassified the death as a homicide. The hospital opened a peer review. The medical board investigated. The family sued. Reporters asked outside doctors and a forensic pathologist "to review O’Keefe’s medical file." None of those readers had been in the room.

Doctors Hospital of Augusta v. Alicea: Supreme Court of Georgia, 2016. This one is about goals of care. A 91-year-old patient's advance directive was filed in the wrong place in her chart. A progress note said her agent had to be called "before patient is intubated." She was intubated overnight without that call. The next morning it took staff 15 to 20 minutes to find the directive. The court affirmed that the defendants were not entitled to summary judgment on statutory immunity. For comfort care the point is simple. Every dose note rests on a goals-of-care decision. Write that decision down, make it specific, and put it where people can find it.

Court decisions

Published decisions, linked to CourtListener.

All decisions behind this guide

From nurses online

Quoted as written. Opinion, not a source.

Other guides

Advice, not law.