Chronic COPD'er, 1 lung, 02 @ 6L/min. What would you do? - page 19

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   shawng007
    i am a well respected lpn, and one thing i always do is respect the patient, and/or the family. the fact that the patient did not want the oxygen increased is enough, add to this the family who is obviously close with their family member. for someone to go against patient wishes is wrong, and also illegal(unless it can be undeniably proven the patient is not able to make those decisions) when patient says NO, that means NO, period, end of story. to provide anything against patients wishes can land you in court. if a doctor orders a procedure on a patient and i go to give it and the patient says no, it doesnt get done regardless what the doctor says, if someone else wants to do it fine, let them get sued, i document pt refusal and let it be. i may try to persuade the patient otherwise but i respect their decision. the paramedic(assuming all the facts are correct in this case) was wrong, regardless of protocol you do not have the right to over rule the patient. period. if that were my family i would sue, and i guarantee i would win too.
  2. by   Sheri257
    Quote from shawng007
    if that were my family i would sue, and i guarantee i would win too.
    I've litigated four cases in court. Not healthcare cases but, I've been in front of a bunch of judges.

    I really have a hard time imagining that any judge would have jumped on anybody's case for putting extra O2 on the patient for 15 minutes, even if it technically violated the patient's wishes when, in fact, the CO2 levels were so high that they probably couldn't have been thinking clearly.

    There was implied consent with the 911 call and there was consent with the intubation so ... the only non-consent issue is 15 minutes in between where you could have killed a lot of brain cells without the O2.

    In this particular situation, it's probably better to defend actions to keep a patient alive than a dead patient who's consent rights are totally intact.

    Let's face it, in a case like this ... people usually don't sue when the patient is still alive. But they're much more likely to sue when the patient is dead.

    And they'd be much more likely, IMO, to sue you for not recognizing that the patient probably wasn't thinking clearly with those high CO2 levels ... than violating any consent rights.

    :typing
    Last edit by Sheri257 on Feb 18, '07
  3. by   shawng007
    again, the patient has the right to refuse, implied consent goes out the door when , on arrival, the patient says NO. ethically, morally, professionally this means one thing, when the patient says NO, this means NO. very simple. any judge or lawyer who disagrees with this is in the wrong field. nurses are there to take care of patients, whether we agree with them or not. if someone takes my car after asking me and i said NO, they would be in trouble for theft, period. if an ambulance comes to my door and i am a COPD'er and they put oxygen on me at 6lpm after i said NO, i guarantee they would one, lose their license, two lose the lawsuit. period. implied consent would apply if the patient said nothing, once the patient says no, that's that. the patient is my cutomer, and i am legally bound to respect their wishes, not to say ethically bound.
  4. by   shawng007
    i must also add that we must treat the patient, not the monitor. an oxygen sat in the 70's for me or you would definitly make us incoherent. a COPDer is accustomed to low sats and would be coherent. instead of looking at the readout, we should assess the patient, if they are sitting up talking to us and coherent, then we should never do what may harm that patient. if a person is on a heart monitor and the line goes flat, do we automatically start CPR or do we first check and find out the patient is talking to us, TREAT the Patient, not the monitor, is the first rule of thumb. monitors are great tools but only in context of the situation. a patient with a BP of 80/40 may raise concerns, but if we look at their history and find that this is their norm we would not normally do anything about it. we should stop thinking out of textbooks and start thinking.
  5. by   Sheri257
    Quote from shawng007
    TREAT the Patient, not the monitor, is the first rule of thumb. monitors are great tools but only in context of the situation.

    we should stop thinking out of textbooks and start thinking.
    Yeah but a court would look also at the whole picture in hindsight. Since the patient was intubated because the CO2 was so high ... the monitor was obviously right. At that point, IMO, it's game over with the court.

    I could easily see them questioning why you didn't put the extra O2 on ... regardless of what the patient said because it's unlikely they could think clearly with those high CO2 levels.

    :typing
    Last edit by Sheri257 on Feb 18, '07
  6. by   chip193
    Quote from shawng007
    i am a well respected lpn, and one thing i always do is respect the patient, and/or the family. the fact that the patient did not want the oxygen increased is enough, add to this the family who is obviously close with their family member. for someone to go against patient wishes is wrong, and also illegal(unless it can be undeniably proven the patient is not able to make those decisions) when patient says NO, that means NO, period, end of story. to provide anything against patients wishes can land you in court. if a doctor orders a procedure on a patient and i go to give it and the patient says no, it doesnt get done regardless what the doctor says, if someone else wants to do it fine, let them get sued, i document pt refusal and let it be. i may try to persuade the patient otherwise but i respect their decision. the paramedic(assuming all the facts are correct in this case) was wrong, regardless of protocol you do not have the right to over rule the patient. period. if that were my family i would sue, and i guarantee i would win too.
    Shawn:

    (1) No does not always mean no in healthcare. Remember implied consent, consent of minors, etc., etc. This patient is hypoxic and may very well be unable to refuse care based on being incompetant.

    Picture this - you arrive to care for a patient, be it home health or in a facility. At the beginning of your encounter with a patient, he tells you that he does not want to be intubated, have CPR done, or have any other heroic measures. There is no DNR , no HCP, no living will (depending on which state you're in!). Two hours later, the patient is unresponsive and has a respiratory rate of 4. Do you resuscitate this patient?

    (2) You don't have a prayer of winning this in court. You cannot meet the three prongs of malpractice, you can question battery, but a parade of expert witnesses of all types (Paramedics, physicians, RTs, and nurses) will blow your argument out of the water with two simple statements:
    (a) "the patient was hypoxic, so the ability to make an informed decision needs to be evaluated in person by a physician"
    (b) "the increase of oxygen for the short transport will not hurt anyone"

    Chip
  7. by   chip193
    Quote from shawng007
    again, the patient has the right to refuse, implied consent goes out the door when , on arrival, the patient says NO. ethically, morally, professionally this means one thing, when the patient says NO, this means NO. very simple. any judge or lawyer who disagrees with this is in the wrong field. nurses are there to take care of patients, whether we agree with them or not. if someone takes my car after asking me and i said NO, they would be in trouble for theft, period. if an ambulance comes to my door and i am a COPD'er and they put oxygen on me at 6lpm after i said NO, i guarantee they would one, lose their license, two lose the lawsuit. period. implied consent would apply if the patient said nothing, once the patient says no, that's that. the patient is my cutomer, and i am legally bound to respect their wishes, not to say ethically bound.
    Shawn,

    Patients must be able to understand the consequences of refusing care. Someone who is hypoxic and hypercarbic cannot form that thought. You are not legally bound to follow the wishes of someone who cannot form a competant thought.

    Chip
  8. by   chip193
    Quote from shawng007
    i must also add that we must treat the patient, not the monitor. an oxygen sat in the 70's for me or you would definitly make us incoherent. a COPDer is accustomed to low sats and would be coherent. instead of looking at the readout, we should assess the patient, if they are sitting up talking to us and coherent, then we should never do what may harm that patient. if a person is on a heart monitor and the line goes flat, do we automatically start CPR or do we first check and find out the patient is talking to us, TREAT the Patient, not the monitor, is the first rule of thumb. monitors are great tools but only in context of the situation. a patient with a BP of 80/40 may raise concerns, but if we look at their history and find that this is their norm we would not normally do anything about it. we should stop thinking out of textbooks and start thinking.
    Shawn,

    The Paramedic obviously did look at the whole picture. She bumped the oxygen on a hypoxic, hypercarbic patient who was then intubated and placed onto a ventilator in the ER.

    The Paramedic made the right call.

    Chip
  9. by   Sheri257
    Quote from shawng007
    instead of looking at the readout, we should assess the patient, if they are sitting up talking to us and coherent, then we should never do what may harm that patient.
    This is where I defer to the clinical judgement of a lot of the posters on this thread.

    I think Angie O'Plasty put it best: when O2 is severely compromised the body shunts more blood to the brain, which is usually the last organ to shut down. That's why a COPD'er can deceptively appear to be mentating when they're really not.

    If you wait for the brain to go then, it's pretty much game over. So even if you're erring on the side of caution (i.e. temporarily violating consent) and getting them that extra O2 to avoid possible brain damage and death ... I think any court of law would understand that.

    :typing
    Last edit by Sheri257 on Feb 18, '07
  10. by   elizabeth321
    This is the scariest part of posts like this...people that aren't practising nursing according to any policy or procedure....just making decisions based on personal opinion.

    There has to be critical thinking...please make educated decisions, read, take courses and don't ever think you have all the answers.....those are the scariest nurses out there.

    Liz
  11. by   angelique777
    Think this was an emergent situation. Was not present so hard to say if the Paramedic was being unreasonable.........could have been simply following protocol........
    Do not want to pass judgement on a situation I did not witness...but everyone was trying to treat the pt as they best thought they could ........

    Regarding to listening to patients I do know this is very important ..pt have often kept me from making errors.............but because hypoxic pt can often not be rational I absorb what they say keep in in mind but still do what I think best based on my assessments of the patient situation and hx I have.......
    Therefore, regarding the issue of listening to a hypoxic patient I think you take what the patient says with a grain of salt..........my hypoxic pt told me she did not need oxygen and that she could drink all the fluids she wants....when I told her she could not drink anything till the doctor evaluated her..because she just got to the unit had been unstable in ER.....and she has questionable hx of a heart condition that can cause fluid to go into the lungs (CHF) she could not have water till she was seen by admitting PA .....she said I was crazy and had no right to refuse her water...my hypoxic pt was an admit to tele unit with questionable hx chf./SOB.......ER sometimes sends us up patient that they still have not stablized first....she was sent to us off oxygen...............she kept taking off oxygen and kept drinking water.....from faucet ......even after I took away the pitcher of water the clerk brought to the room after I told her the women could not have water...........pt sounded coherent to everyone so they thought I was being difficult.........pt also would refuse bed rest.........to every one they thought she was axox3 told me to leave her alone thought I was being unreasonable to refuse her any water..and to keep her on bedrest..since she was a walkie talkie......NSR on tele.......I got a CNA to help me put her back in bed I had to call family to get her to listen to me.......I called PA........I told her she was desating and refusing treatment.........I called respiratory........despite what others thought I kept on top of my pt to get her treatment ........women crashed and went into respiratory failure ......but made it and never coded thank God......since I did not listen to the patient ...........all the right people where in the room when the women crashed....outwardly the patient seem to make sense to everyone..so much so that even when the PA came to talk to the pt and she complained to the PA that I would not let her sit on the edge of the bed the PA said oh it ok you can sit up on the edge of the bed..........It is the first time I ever got upset with this PA cause she is really great person.and a good PA.......I told her please do no tell my pt its ok cause she is not stable and I do not want to pick her up off the floor ......I told the PA she was not here to see that this pt is not stable......as I was telling the PA this the women crashed.........this is how coherent this person sounded to every one...she sounded coherent but she was desating ..................to me she was hypoxic and irrational and danger to herself.....The out come was she ended up intubated .........treated and later had to transport her to respiratory critical care unit............I went to see her the next day and she apologized to me for having been such a pain in the butt when she came to the unit and she knows now I was just trying to keep her alive...........
    Last edit by angelique777 on Feb 18, '07
  12. by   shawng007
    actually, it doesnt matter what the end result is, the patient has the right to refuse, and as i said, NO means NO.
  13. by   ZippyGBR
    Quote from earle58
    i know it was ingrained during nsg school, to never give beyond 2-3l/min to one w/copd, since high o2 levels decrease their stimulus to breathe.
    but looking at the big picture, i've since learned that short term high flo o2, is not damaging and in many instances, a life-saver.
    if choosing between the lesser of 2 evils, i'd rather see them acidotic and vented than dead.
    so i've had to 'unlearn' much of what's been taught and relearn what their absolute realities are.
    however, this is not written in stone and if a pt told me not to use high flow oxygen, i'd have to question their personal experiences and give them benefit of my doubts.

    leslie
    except of course there is a strong chance they are dead to all intents and purposes the moment you decide to go with invasive ventilation on a patient with this clinical picture

    he will be a hard wean if you can wean him

    he only hads one lung

    he has COPD and type II respiratory failure

    the 'first do no harm ' option is carefully titrated Oxygen therapy and good active , supportive treatment ( antibitoics, walking the tight rope of blood gasses with the titrated o2 therapy), maybe look at NIV modalities if the patient can tolerate NIV, but an ETT or trache is a death warrant

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