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 felt it should be coming up after breathing treatments and wanted to call before it got too late in the evening.
She/he is a chronic COPD'er, who has only one lung, who functions well with 02 sats in the low 80's. She/he has 02 BNC @ 2.5L/min. When I got there she/he was sitting up talking to me. She/he said she/he didn't feel in the least SOB, 02 sat was 73%, Temp 102 and her/his one lung was full of wheezes. I felt as though she/he should go to the hospital but that it was not an emergency situation. The family fully agreed. They said she/he preferred to go by ambulance so she/he wouldn't have to sit in the ER. I agreed. We called 911.
An EMT got there and asked what was going on. I told him. A few minutes later the ambulance got there and a paramedic came in. She saw me but asked the EMT what was going on. "Oh my God a sat of 73% crank her up to 6L/min. I said no. I explained why. She said "well we have to get her 02 sat up because she's not perfusing 02 to her brain. I said she's talking to you. Please do not turn her up to 6L/min you'll do more harm. She did it anyway. The daughter said "the last time you guys did this she/he ended up with a CO2 of 134 and ended up on a ventilator". The patient said please don't do this to me. The paramedic ignored everyone. The EMT turned it back down to 2L/min the paramedic saw it and turned it back up to 6L/min. She told the patient she would put her/him on a non-rebreather once they got her/him in the ambulance!
I was told that once the paramedics arrive they are in charge and what they do is their responsibility but how ignorant to not listen to the nurse, the family and the patient?
I will make sure this paramedic gets reported. I wonder what you guys thoughts are?
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.
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.
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.
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:D )
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.
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.
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.
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.
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.
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.
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"
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:D )
UM Review RN, ASN, RN
1 Article; 5,163 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.