Specifications Manual for Joint Commission National Quality Measures (v2023A)
Posted: 08/12/2022
Home » Comfort Measures Only

Release Notes:
Data Element
Version 2023A

Name:Comfort Measures Only
Collected For: ACHF, ASR-IP-2, ASR-IP-3, ASR-OP-2, CCCIP-01, CCCIP-02, CCCIP-03, CCCIP-04, CCCOP-01, CCCOP-02, CSTK-01, CSTK-03, CSTK-04, CSTK-06, STK-1, STK-10, STK-2, STK-3, STK-5, STK-6, STK-8, STK-OP-1, SUB-2, SUB-3, TOB-2, TOB-3, VTE-6
Definition:Comfort Measures Only refers to medical treatment of a dying person where the natural dying process is permitted to occur while assuring maximum comfort. It includes attention to the psychological and spiritual needs of the patient and support for both the dying patient and the patient's family. Comfort Measures Only is commonly referred to as “comfort care” by the general public. It is not equivalent to a physician order to withhold emergency resuscitative measures such as Do Not Resuscitate (DNR).
Question:When is the earliest physician/APN/PA documentation of comfort measures only?
Allowable Values:

1   Day 0 or 1: The earliest day the physician/APN/PA documented comfort measures only was the day of arrival (Day 0) or day after arrival (Day 1).

2   Day 2 or after: The earliest day the physician/APN/PA documented comfort measures only was two or more days after arrival day (Day 2+).

3   Timing unclear: There is physician/APN/PA documentation of comfort measures only during this hospital stay, but whether the earliest documentation of comfort measures only was on day 0 or 1 OR after day 1 is unclear.

4   Not Documented/UTD: There is no physician/APN/PA documentation of comfort measures only, or unable to determine from medical record documentation.
Notes for Abstraction:
  • Only accept terms identified in the list of inclusions. No other terminology will be accepted.
  • Physician/APN/PA documentation of comfort measures only (hospice, comfort care, etc.) mentioned in the following contexts suffices:
    • Comfort measures only recommendation
    • Order for consultation or evaluation by a hospice care service
    • Patient or family request for comfort measures only
    • Plan for comfort measures only
    • Referral to hospice care service
    • Discussion of comfort measures
  • Determine the earliest day comfort measures only (CMO) was DOCUMENTED by the physician/APN/PA. If any of the inclusion terms are documented by the physician/APN/PA, select value “1,” “2,” or “3” accordingly.
    "Discussed comfort care with family on arrival" noted in day 2 progress note -— Select “2.”"
  • State-Authorized Portable Orders (SAPOs).
    • SAPOs are specialized forms or identifiers authorized by state law that translate a patient”s preferences about specific end-of-life treatment decisions into portable medical orders
      • DNR-Comfort Care form
      • MOLST (Medical Orders for Life-Sustaining Treatment)
      • POLST (Physician Orders for Life-Sustaining Treatment)
      • Out-of-Hospital DNR (OOH DNR)
    • If there is a SAPO in the record that is dated and signed prior to arrival with an option in which an inclusion term is found that is checked, select value “1.”
    • If a SAPO lists different options for CMO and any CMO option is checked, select value “1,” “2,”" or “3”" as applicable.
    • If one or more dated SAPOs are included in the record (and signed by the physician/APN/PA), use only the most recent one. Disregard undated SAPOs.
    • For cases where there is a SAPO in the record with a CMO option selected: If the SAPO is dated prior to arrival and there is documentation on the day of arrival or the day after arrival that the patient does not want CMO, and there is no other documentation regarding CMO found in the record, disregard the SAPO.
      Patient has a POLST dated prior to arrival in his chart and ED physician states in current record “Patient is refusing comfort measures, wants to receive full treatment and be a full code.”
  • Documentation of an inclusion term in the following situations should be disregarded. Continue to review the remaining physician/APN/PA documentation for acceptable inclusion terms. If the ONLY documentation found is an inclusion term in the following situations, select value “4.”"
    • Documentation (other than SAPOs) that is dated prior to arrival or documentation which refers to the pre-arrival time period.
      • Comfort measures only order in previous hospitalization record.
      • “Pt. on hospice at home” in MD ED note.
    • Inclusion term clearly described as negative or conditional.
      • “No comfort care"
      • "Not appropriate for hospice care"
      • “Comfort care would also be reasonable - defer decision for now”"
      • “DNRCCA”" (Do Not Resuscitate -— Comfort Care Arrest)
      • “Family requests comfort measures only should the patient arrest.”
    • Documentation of “CMO”" should be disregarded if documentation makes clear it is not being used as an acronym for Comfort Measures Only (e.g., “hx dilated CMO” -— Cardiomyopathy context).
  • If there is physician/APN/PA documentation of an inclusion term in one source that indicates the patient is Comfort Measures Only, AND there is physician/APN/PA documentation of an inclusion term in another source that indicates the patient is NOT CMO, the source that indicates the patient is CMO would be used to select value “1,” “2,” or “3”" for this data element.
    • Physician documents in progress note on day 1 “The patient has refused Comfort Measures” AND then on day 2 the physician writes an order for a Hospice referral. Select value “2.”
    • ED physician documents in a note on day of arrival “Patient states they want to be enrolled in Hospice” AND then on day 2 there is a physician progress note with documentation of “Patient is not a Hospice candidate.” Select value “1.”
  • Consultation notes
  • Discharge summary
  • Emergency department record
  • History and physical
  • Physician orders
  • Progress notes
Additional Notes: Excluded Data Sources:
  • Restraint order sheet
Guidelines for Abstraction:
Inclusion Exclusion
  • Brain dead
  • Brain death
  • Comfort care
  • Comfort focused treatment
  • Comfort measures
  • Comfort measures only (CMO)
  • Comfort only
  • DNR-CC
  • End of life care
  • Hospice
  • Hospice care
  • Organ harvest
  • Terminal care
  • Terminal extubation


Comfort Measures Only
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Specifications Manual for Joint Commission National Quality Measures (v2023A)
Discharges 01-01-23 (1Q23) through 06-30-23 (2Q23)


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