Respiratory Therapists Stingy with o2? - page 2

by haji

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This has happened to me twice recently. I have had some very sick patients on bipap (DNR) who were near death. When the patients desaturated, and I suggested to the respiratory therapist (both times already at the bedside with... Read More


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    If they are a DNR with advanced interventions like acls meds and such, then yes I agree the BIPAP should get turned up. Otherwise, the previous posters are right that there is no point.

    I actually like the concept of DNR with meds and such, but not for any reason other than this - it helps the family start heading down the slope of letting the person die. It's a lot harder to go from a full code to a DNR comfort care only than it is to go from a full code to, pretty much full code except we're not going to break their ribs or put a tube down their throats. Obviously we as health care providers know that it's pretty close to pointless to push ACLS drugs if the heart's not beating, but I think it helps the family feel that they did everything for the person that they would want.
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    I my opinion...if death is imminent...100%FIO2 won't prevent them from dying....so if they are struggling there is NO REASON not to try to make them as comfortable as possible. Sometimes it is important to comfort the living by comforting the family. The patient is going to die.... we ALL know that...but if turning up the O2 will comfort the family then I see no problem with it...it' not like you are adding any expense to the bill.
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    The only time I would ask to have the fio2 turned up is if the pt looked like he was gasping for air. I agree with everyone else that it would have done anything, but if they are actively dying with no morphine gtt or palliative care on the case, I would try to make the pt as comfortable as possible. If the pt was comfortable, but hypoxic, then there's nothing to do with the fio2 as long as the pt is at peace.
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    Quote from haji
    This has happened to me twice recently. I have had some very sick patients on bipap (DNR) who were near death. When the patients desaturated, and I suggested to the respiratory therapist (both times already at the bedside with me) to turn the fio2 up to 100%, they balk and only go up to 50%. So I have to go over myself and push the buttons. Both patients died pretty soon after this despite some improvement in sat. I don't think the patients died because of hypoxemia.
    Anyway, it just seems crazy to me, if somebody is hypotensive, desaturating, and barely alive, why be stingy with the o2? Has anybody else had this issue?
    If this patient is a DNR and is on BiPAP, chances are the decision has been made to treat the patient aggressively which will probably take more than O2. Giving more oxygen may just mask the situation and delay more definitive treatment. Sometimes the "easy" fix is not the correct one and can make the situation worse. 100% oxygen also create a nitrogen wash out increasing atelectasis and toxicity which will increase the probability of death and cause more discomfort.

    What about fluids? Pressors?

    If the blood pressure is low, the perfusion will be inadequate. No amount of O2 will help until the MAP is higher to promote perfusion.

    Was this patient really dying and were there comfort measures in place? It is a horrible situation to be stuck on something as uncomfortable as BiPAP while dying and not have adequate comfort measures such as sedation and pain management. That is just cruel and unnecessary punishment. Chasing O2 sats is not the answer when the tissues can not longer utilize the oxygen. This is why standard comfort care orders are 2 - 4 L/ NC with discomfort issues addressed by IV and/or nebulized meds like fentanyl or morphine.

    The other issue is where the patient is located. Since BiPAP is a rescue machine, most hospitals will have policies in place that any BiPAP patient needing higher than 50% O2 needs to be transferred to a higher level of care. That includes DNRs who are being treated by BiPAP unless there are special parameters written in a comfort measure order. That is rare since there is then an ethical issue for mechanical ventilation including the use of BiPAP. But, if there was a policy in place requiring no more O2 than 50% to be given while in your area, you have have violated it. The RT could make an issue out of this and the BiPAP machine will be their witness since it records every time you "push" a button including FiO2 and Alarm Silence.

    I suggest you read the BiPAP policy for your floor. If it and the order written by the physician is in conflict, the Medical Director (Pulmonologist) of RT will need to be contacted immediately by your supervisor and the RT supervisor to have a serious discussion with that doctor. Nurses and RTs have gotten themselves into serious problems when they did not follow the hospital's protocols when it came to BiPAPs and vents. JCAHO is very, very big on this one for safety even if the patient is "dying". You should not be the one who brings death sooner unless it is a planned termination.
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    Wow, I guess I should just start a morphine drip the next time I respond to an Rapid Response call on the floor for a DNR or Limited code patient. Or maybe just refuse to treat them and go back to the unit.
    And never give anyone 100% fio2 because it might kill them.
    Thanks for the help.
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    Quote from haji
    Wow, I guess I should just start a morphine drip the next time I respond to an Rapid Response call on the floor for a DNR or Limited code patient. Or maybe just refuse to treat them and go back to the unit.
    And never give anyone 100% fio2 because it might kill them.
    Thanks for the help.

    I think you have taken the wrong attitude.

    The question is why does the patient need 100% O2 and is there something that can be done to make them more comfortable. Just increasing the FiO2 will not help if the tissues have already stopped utilizing oxygen. If the patient is going to be comfort care then you should consider running the protocol to make them comfortable which includes meds like morphine and not increasing the FiO2. Being stuck on a NRB mask or BiPAP is a horrible way to die. 2 -4 L NC is often the Comfort Care protocol with an adequate titration of medications for comfort.

    But, if the patient is a DNR, at what point is the doctor going to give up? DNR and Comfort Care are not the same thing. DNR also does not mean do not treat. If this patient exceeds the parameters in the protocols for your floor then they need to be moved to a higher level of care or mayby not accepted to your floor. There is a reason why some hospitals have protocols to not have BIPAP machines with an FiO2 requirement of greater than 0.5 on a med surg floor. If the patient needs more than that then they are in need of a higher level of care with more meds or therapies than what you have to offer. Can Nitric Oxide or Heliox be used on your floor? What pressors can you hang? How many patients do you have since a patient this sick who is not comfort care will require extensive monitoring?


    Also, don't underestimate the damage which can be done by leaving someone on 100%. If this patient is not comfort care and not going to die within the next day or two, you have not done them any favors. Remember a high FiO2 is only meant to be temporary until a more definitive intervention(s) is achieved. It is not meant to be "okay the sats are fine now on 100%" and walk away. Thus, when the patient's SpO2 again starts to decline, you have now lost that much more time which will be crucial in a critically ill patient and are now way behind the 8 ball.


    Sorry if I repeated what I stated in my previous post. But, the point is a decision must be made as to the agressiveness of the treatment. Just increasing the FiO2 does not provide a definitive solution for either comfort care or treatment beyond a few minutes.
    Altra likes this.
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    Why even check the O2 saturation on a dying patient? I get using Bipap as a comfort measure, but at that point, why worry about numbers? You don't care for the dying based on numbers, you go by comfort. If they weren't uncomfortable, let them and their oxygen be.
    Altra and Esme12 like this.
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    Quote from haji
    Wow, I guess I should just start a morphine drip the next time I respond to an Rapid Response call on the floor for a DNR or Limited code patient. Or maybe just refuse to treat them and go back to the unit.
    And never give anyone 100% fio2 because it might kill them.
    Thanks for the help.
    Turn the question around: what IS going to be accomplished by going up to 100% FiO2?

    I'd suggest discussing this with a nurse on your unit who has preceptored or mentored you, your unit educator, or even a doc with whom you have a good relationship. You might also need some time to reflect on the clinical knowledge you have about the cascade of the dying process and integrating this knowledge with your belief system.
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    My belief system? The cascade of the dying process?
    Is this about nursing theory?

    Are any of you icu nurses?
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    Haji, I assure you ... my post was not about nursing theory. It was never really my thing at all.

    I am an ICU nurse, in an academic tertiary care hospital. There is as much dying as there is "saving" in an ICU, in my experience. I sensed a lot of discomfort with this reality in your posts on this thread -- particularly in the post I quoted. I am suggesting that you might want to reflect on this to better understand where your discomfort lies.

    So physiologically (the cascade of the dying process I referred to earlier) -- what is gained by turning up the FiO2?


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