Chronic COPD'er, 1 lung, 02 @ 6L/min. What would you do? - page 18

I got a call to go see one of my HH patients, who I am very familar with, because the family reported that her/his 02 sats were hanging in the 70's all day and even though she/he was not SOB they... Read More

  1. by   Sheri257
    Quote from Angie O'Plasty, RN
    Please note that Lizz was referring to a potential NCLEX question.
    Yeah but ... you can't dismiss that either. One of my teachers occassionally does some legal consulting and what she does is research what the latest nursing textbooks say about standards of practice for law firms.

    If three or more textbooks pretty much say the same thing then, the lawyers can and will use it. That's what the lawyers are looking for.

    And, there's a lot of textbooks that hammer on the "no more than 2L" COPD issue ... at least for nurses. Obviously based on these posts, it could be different for EMT's, etc.

    Not that I'm saying that textbooks are the be all end all for legal cases but ... you can't dismiss it either because it could be a factor.

    :typing
    Last edit by Sheri257 on Feb 9, '07
  2. by   cardiacRN2006
    Quote from lizz

    and, there's a lot of textbooks that hammer on the "no more than 2l" copd issue ... at least for nurses. obviously based on these posts, it could be different for emt's.

    :typing

    it is different for pre-hospital textbooks.

    this is right out of a paramedic textbook, page 303...
    "delivering an increased concentration of oxygen may increase the pao2, and therefore eliminate the drive to breathe. note: do not withhold oxygen from a patient who needs it. if you are concerned about eliminating the patient's hypoxic drive, be prepared to manage the airway."

    how to prepare for the emt paramedic exam (paperback)
    by [color=#003399]mark marchetta (author)




    also, straight out of my nursing textbook,

    "the nurse monitors clients at risk for oxygen-induced hypoventilation, apnea, and respiratory arrest. although oxygen induced hypoventilation is a serious concern, untreated or inadequately treated hypoxemia is a greater threat to life."
    medical-surgical nursing, ignatavicius and workman, pg 491


    the italics are the actual italics in the wording of the textbook, not my own.
    Last edit by cardiacRN2006 on Feb 9, '07 : Reason: Can't spell Iggy...
  3. by   RXCT
    That book is right...
  4. by   Broombug
    it is different for pre-hospital textbooks.

    this is right out of a paramedic textbook, page 303...
    "delivering an increased concentration of oxygen may increase the pao2, and therefore eliminate the drive to breathe. note: do not withhold oxygen from a patient who needs it. if you are concerned about eliminating the patient's hypoxic drive, be prepared to manage the airway."

    how to prepare for the emt paramedic exam (paperback)
    by [color=#003399]mark marchetta (author)




    also, straight out of my nursing textbook,

    "the nurse monitors clients at risk for oxygen-induced hypoventilation, apnea, and respiratory arrest. although oxygen induced hypoventilation is a serious concern, untreated or inadequately treated hypoxemia is a greater threat to life."
    medical-surgical nursing, ignatavicius and workman, pg 491


    the italics are the actual italics in the wording of the textbook, not my own.
    i agree with cardiacrn2006.

    i didnt read every post but this is a sad discussion. i am a rn/rrt and i dont understand how anyone would even think that denying a severly hypoxic patient, copd or not, oxygen would be the right thing to do. hypoxic patients are confused and are not the best decision makers. sometimes i know some nurses, patients and family caregivers, view hyperventilating as s.o.b. not hypoventilating as this patient was doing.

    if this patient's saturations were really in the 70s when the paramedic arrived then the patient was already hypoventilating meaning his/hers co2 was most likely sky high at that moment. 2 or 6 l/m o2, i'm willing to bet, didnt make any difference on whether this patient "bought the tube" or not. only a dnr in writing would have.

    as a matter of fact it sounds to me the er doc felt that the patient needed more than 6l/m if he tubed him/her and placed them on a vent.

    if you dont want the ems or any other medical proffesional to treat you when you are dying, please look into in and out-of-hospital advanced directives and living wills before an emergency occurs.
  5. by   Sheri257
    Edited for error.
    Last edit by Sheri257 on Feb 10, '07
  6. by   withasmilelpn
    Quote from Angie O'Plasty, RN
    Am I sensing sarcasm here, withasmilelpn?

    Please note that Lizz was referring to a potential NCLEX question.

    If a lawyer was asking my rationale for upping the O2, my answer would be:

    Giving supplemental oxygen is the standard of care for any patient in an emergent situation.

    I believe we already established earlier in the thread that the patient's situation was truly emergent.
    No, not towards you. I really love all the great information you posted. I meant what I said, the post was fascinating. What I really feel though that we as caregivers constantly try to muddle through these 'grey' areas and try to give good care to our patients, and in the end it could rest in the hands of a non medical person to decide if you gave appropriate care. Please keep posting, I always learn a lot from your posts!
  7. by   UM Review RN
    Quote from lizz
    Well ... now I'm confused more than ever. There doesn't seem to be any consensus on this issue.

    Many of the posters on this thread had me convinced that 6L O2 for 15 minutes wouldn't do much damage and, even if it did, it's better than dead brain cells.

    And, as I recall, many cited research that extra O2 for a few minutes wouldn't do much damage.

    Now, I'm doing Kaplan questions for the NCLEX and they're saying even 2L O2 can put a COPD patient into respiratory arrest in as little as 20 minutes if it kills the hypoxic drive.

    I know this is academia and not the real world but ... this is really confusing.

    My only solution is to go back to the original NCLEX test prep question, which does not adequately compare to the actual situation that this patient experienced.

    In order to understand the Kaplan question better, maybe we need to answer a question with a question:

    If even O2 at 2L can put a COPDer into respiratory arrest in 20 minutes, why do we give them O2 in the first place? Have you ever seen a COPDer who did not get O2 at 2L?
  8. by   UM Review RN
    Quote from withasmilelpn
    No, not towards you. I really love all the great information you posted. I meant what I said, the post was fascinating. What I really feel though that we as caregivers constantly try to muddle through these 'grey' areas and try to give good care to our patients, and in the end it could rest in the hands of a non medical person to decide if you gave appropriate care. Please keep posting, I always learn a lot from your posts!
    That's true, non-medical lawyers will try to pick apart every detail of care rendered--and not rendered. There are gray areas, to be sure, and apparently this is one of them.

    I guess in the end we all have to do what we believe is the best, most appropriate treatment for our patients.

    Had this been me, I would've turned up the O2 on this patient because the patient was not at baseline and had a fever, indicating that he/she was about to crash in a big way. I would've been quite comfortable with that decision in all areas--morally, legally, and ethically.

    And I thank you for clarifying your post. I do appreciate it. The one thing that rings true in all the posts on this thread is that, whether we would've turned up the O2 or not, for whatever reason, each and every person was thinking of the patient's best interests.
  9. by   burn out
    [quote=lizz;2060570]

    Kaplan says you wouldn't see a COPD patient with a PaO2 of 70 percent first because, 70 percent is considered "normal to good" for a COPD'er and, therefore, this is a stable patient. Quite different from what a lot of people have been saying on this thread.

    Just to keep the facts straight the Saturation was 70% not the pao2. Yes a pao2 of 70 for a COPD'er is considered good but not a saturation. We do not know what the pao2 is we didn't have an abg at the home. Saturation levels measure the percent that the hemoglobin is carryng oxygen whereas the pao2 measures the partial pressure of oxygen in the blood..two different measurements.
    Last edit by burn out on Feb 9, '07
  10. by   Sheri257
    Quote from burn out
    Just to keep the facts straight the Saturation was 70% not the pao2. Yes a pao2 of 70 for a COPD'er is considered good but not a saturation. We do not know what the pao2 is we didn't have an abg at the home. Saturation levels measure the percent that the hemoglobin is carryng oxygen whereas the pao2 measures the partial pressure of oxygen in the blood..two different measurements.
    I see your point.

    :typing
    Last edit by Sheri257 on Feb 10, '07
  11. by   withasmilelpn
    Quote from Angie O'Plasty, RN
    That's true, non-medical lawyers will try to pick apart every detail of care rendered--and not rendered. There are gray areas, to be sure, and apparently this is one of them.

    I guess in the end we all have to do what we believe is the best, most appropriate treatment for our patients.

    Had this been me, I would've turned up the O2 on this patient because the patient was not at baseline and had a fever, indicating that he/she was about to crash in a big way. I would've been quite comfortable with that decision in all areas--morally, legally, and ethically.

    And I thank you for clarifying your post. I do appreciate it. The one thing that rings true in all the posts on this thread is that, whether we would've turned up the O2 or not, for whatever reason, each and every person was thinking of the patient's best interests.
    Yep! Exactly what I would've done as well. Doing what you think is best for your patient, based on your knowledge is the way to go. I think what these posts all prove is how much we all are trying to give our patients the best care possible. Not a bad thing at all! (And you are welcome )
  12. by   fr.dad
    Thank you DutchgirlRN for initiating this discussion. I am sorry the pancreatitis was not resolved and the patient died. - Many issues and aspects of this case have been discussed here. I, too, have learned by reading the entire thread. Yet I am still wondering about a some things. - First, let me say I am not a nurse. I am an EMT, a firefighter, and a priest. I sit on the Ethics Committee of our community hospital. Other contributors have more medical knowledge than I, so I shall not address the medical details. Rather, my questions have to do with the human interactions and the ethical issues, both at the scene and here in this internet discussion. - DG began with a good summary presentation of a sad situation. It is disappointing that a several writers who posted responses did not bother to pay attention to the facts as presented. I suppose that is human nature, but it is not helpful when respondents assume facts contrary to what is known about the case under discussion. I pray no one here practices their medical profession in the same way. [Although I once had this surgeon trying to attend me without reading the chart . . .] - I, too, have cared for patients in respiratory distress. Yes, they can have altered levels of consciousness, and can even be combative. But clearly this does not describe DG's patient! This patient was sitting up, conversing, denying SOB. She had been playing cards with her daughter, shopping on eBay, and eating her meals. - All participants here, as well as DG, the medic, and the EMT at the scene, have been concerned with several of the same ethical duties. That this case is both difficult and interesting stems from differing perceptions of the treatment these duties require. Specifically, both DG and the medic have a duty to help the pt and a duty to do no harm to the pt, but they perceive the facts differently so those duties impel them to act differently. DG finds her duty from the perspective of longer term care for the pt. Over time, high O2 rates will harm the pt. The medic has a short term, emergency care time frame. In the short term, from to arrival at the ED, low O2 rates will harm the pt. Conflict. - Patient autonomy is another issue here. Several writers have gone way off on tangents, assuming other facts, to justify overriding the pt's objections. Very little attention was paid to the pt's actual state of mind. Both RNs and medics are taught to perform basic assessments of a pt's mental status. It might have helped resolve the conflict if those skills were used and the results applied to the treatment decisions during transport, if transport by ambulance were to happen at all. The medic might have even offered the pt a choice between accepting the ALS protocol of higher flow O2 or refusing ambulance care. In spite of some of the silly rhetoric on this thread, such refusals happen all the time. They are a routine part of the ambulance business. Patient autonomy includes the right of a competent pt to refuse care. Several have called her mental competency into question based solely on the O2 sat of 73% without assessing the patient. That is not ethical medical care for any of us. - There is an issue of distributive justice in this case also. Ambulance availability is a limited resource. The demand often is greater than the supply. There were some posts on this topic. DG states repeatedly her professional judgment that this was not an emergency. The stated motive for using the 911 ambulance was to try to bypass the waiting room. In post #19 DG even responds to NREMT-P/RN with a facetious, "This NOT SICK patient is then an emergency? [DG's emphasis]" That means this NOT SICK patient does not need to take and emergency ambulance and crew out of service, placing the well being of the rest of the community at risk due to delayed response. Tell the family to find another way, a non-emergency way, to have the pt transported. Call a taxicab. Or some other community resource. - Or do not transport. Clearly this pt is very debilitated. she certainly seems to be in decline. What is the therapeutic goal of this hospitalization? Is she a suitable Hospice candidate? Has Hospice been considered? She is not going to recover from her advanced COPD. Is this return to the hospital for the sake of prolonging an imminent death? That is not such a good reason. Just what does the DNR document call for? Just what instructions have the pt and the DPOA put into writing? Clearly the patient and family do not want a mechanical ventilator, so what do they want from the hospital. If they are looking for unrealistic miracles when they should be preparing for an approaching death, then calling an ambulance does not help anybody. These issues are not the medic's responsibility. Maybe they are or are not the HHRN's responsibility, but they are certainly the responsibility of the Home Health Agency. They are a responsibility shared by the hospital and should have been considered in the discharge plan 48 hours previous to this incident. - Speaking of the hospital, the conditions in that ED waiting room, as described by DG, are unacceptable. I know they happen, but they violate all sorts of ethical standards. - And the MD who abandoned his pts by allowing his emergency number to be connected to a fax, ought to be reported. Pt abandonment is both an ethical violation and a crime. - The patient's DNR status and the presence of a DPOA [presumably you mean a durable power of attorney], and the MD's order to never increase the O2 above 2.5L/min are things that only came out as the discussion progressed. I wonder, when the conflict developed with the medic, why did the family not invoke the DPOA? I wonder also whether the DNR status was ever communicated to the medic? It has no effect if it is not. Was that O2 order shown to the medic? Was it in writing? - Unfortunately we do not know what the medic's assessment of the pt was at the time or just why she followed the course she chose. Several writers have explained persuasively why they found the medic's actions correct, others have faulted her for one reason or another. She found herself in a conflicted situation and may have thought that minimizing the conflict and quick removal was the best for the pt. But the pt. might have been better served by greater attention to pt assessment. - These are the sorts of issues I would raise if this were to come before our Ethics Committee. I doubt any of them contributed to the pt's death, but learning from this case can help improve the care we give other pts.
    Last edit by fr.dad on Feb 12, '07 : Reason: paragraph spacing - I can't fix it, sorry
  13. by   DutchgirlRN
    Thank you fr.dad. Excellent post.

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