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Danger to self? help!

Posted

I work long term care, and we recently had a patient return from the hospital on palliative care (family did not want to pay for hospice until medicaid kicked in... also would not pay/consider having a patient sitter to stay with the patient in her final days :uhoh3:) Anyway... when she came back, her lungs sounded horrible and she had an O2 sat of 88% on 4LPM by NC. MD aware, family wanted her in LTC, so we kept her. She would shift between 90-95% on 4LPM. Gradually, she began to wake up and was very agitated. She would repeatedly remove her NC and try to climb out of bed (bed low, floor mat). Called the MD and he ordered ativan. Problem was though, that we couldnt get it until about 7 hours later, because pharmacy only delivers 2x a day. Of course, borrowing was not acceptable in this scenario. I told the MD that we had haldol, phentergen and benadryl available if he wished to use those instead. Eventually, he decided to go with 1x dose 25mg benadryl... but he was irritated about doing so, since he "needed a reason to prescribe" and she wasnt sneezing. He kept asking me "is she a danger to herself or others?".... Which really made me think. Danger to others? Certainly not. Danger to herself? Possibly. By removing her NC and allowing her O2 to drop, she is unknowingly a danger to herself (since she was so confused with demenia, she was not aware of the consequences of her actions).

Would you consider a dementia patient who removes life-sustaining O2 a "danger to self"?

etaoinshrdluRN

Specializes in LTC, OB, psych. Has 2 years experience.

She might well harm herself by removing oxygen, but with the demented, it's one of those things that sometimes can not be helped. In similar situations I have done oxygen blowby. Benadryl sometimes has paradoxical effects, making patients uncomfortable and restless, along with the anticholinergic stuff.

To me, this is a matter of resident rights, or perhaps POA wishes.

A contingency box for narcs is nice to have around. The delay would consist only in the time it takes to get an access code from a pharmacist.

Edited by etaoinshrdluRN

Jules A, MSN

Specializes in Family Nurse Practitioner.

FWIW I'm not a fan of Ativan for pts with dementia because in my experience it can make things worse. Imo it sounds to me like yes she was a danger to her self although I don't see why the order couldn't have been written as prn for agitation. Aren't docs in LTC used to handling this kind of thing? :confused:

nurse2033, MSN, RN

Specializes in ER, ICU.

Removing a canula that is keeping you alive sure is a danger. I would have said "yes" to the doc and made it clear the patient needs A) some form of mild sedation B) restraints or C) a sitter since you can't watch her every minute and she could easily remove her oxygen and die. Obviously B would be a last resort and C probably not possible. I agree with Jules that Ativan can have goofy effects on people.

dmc_rrt

Has 5 years experience.

I understand she was palliative, so the main objective here is to make the pt. and her family comfortable. The removal of O2 should not have been a problem, the lack of proper sedation is more of a problem.

tyvin, BSN, RN

Specializes in Hospice / Psych / RNAC.

She was a a high risk for falls since she was agitated with dementia and was attempting to get out of bed but you had the proper things in place. The doc was trying to get you to throw him a bone.............if she's agitated and trying to get out of bed I would be concerned about the other residents as you don't know what she was capable of (danger to others) and herself as she would more then likely suffer a severe fall if successful in getting out of the bed regardless of low bed and mats.

Davey Do

Specializes in around 25 years psych, 10 years medical. Has 42 years experience.

Trubie:

First, let me note that I was impressed with your reporting style: Clear, concise, and to the point.

Sure, she was a threat of harm to herself. And ojective charting can be done in a creative manner in order to assure that the documentation reflects that the med is given for appropriate reasons.

Some Docs I've worked with have ordered Benadryl 50 mg IM now for agitation with acting-out Adolescent Inpts. It seems to work. For whatever reason, whether it be the sedating effect of an anticholengeric or the act of receiving an IM. Regardlessly, your Doc was not far off base.

From my experience, I've found that the dopamine-antagonist antipsychotics work really well at decreasing agitation. A typical dose for a Geriatric Patient could be Haldol 1 to 2 mg. Zyprexa 5 to 10 mg is even better. Both can be given IM or PO.

In the Institution I currently work for, we cannot have prn orders for "agitation". We call it "psychosis". Some Surveying Entity interpretted the agitation thing as a forced chemical restraint. Even if the Patient took it of their own volition. Go figure.

Good question. Good discussion.

Dave

Cinquefoil

Specializes in Med Surg, Home Health. Has 2 years experience.

In my facility we have a very elderly lady who had O2 levels of 85 when last measured by the Hospice RN. Hospice RN got her agency NP to prescribe NC Oxygen.

Now I know this resident very very well, and the odds of her deciding to keep a cannula on are minimal.

She's on hospice, though, where the focus of care shifts from an emphasis of "removing all dangers from the patient so they can heal" to "respecting the dignity and overall comfort of the patient so they can better experience their last days/weeks/months of life". And the hospice RN said, when I mentioned the tube-on-nose thing might be a tough sell, "Please don't give O2 if it's not her wish; I just want the O2 available in case it COULD help her comfort." I assured her that at my facility we're not in the habit of overriding resident's wishes.

Of course we did override that frail little resident (very strong dementia on an open door facility) when she wanted to go tiptoe among the tulips in the icy rain in October to go home because we were cruelly holding her in a strange person's room! (With her picture on the wall, her bedding, her belongings, which she could no longer recognize.....poor thing.) We babysat her and physically turned her away from the door until a bed opened up in a locked unit. But we overrode her wishes because she would have wandered away from where anyone could have taken care of her, not to mention she could have been hurt by strangers, and IT WAS COLD! and it's not OK to kill hospice patients thru neglect.

If your patient is appropriate for hospice and receiving palliative care in lieu of hospice then IMHO (and I'm only a hospice nurse wannabe so far) she was more in danger of "hurting" herself through climbing out of bed and falling rather than removing her O2 equipment.

I mean, sure, the lack of O2 will hurt and/or kill her. And the process of slow O2 starvation can't be comfortable. However, if the O2 equipment is causing psychological distress worse than the physical pain, so much that she wants to remove it, it may be "better" for her to leave it off. Even patients who aren't on hospice are allowed to choose whether or not they want medical interventions, right? even if it ends in their death?

Of course if she were to become unresponsive that would be a whole different ballgame IMHO unless she had advance directives that clearly addressed her wishes.

A partly different ballgame: if the O2 equipment is not CAUSING the agitation, if the agitation and wandering continues no matter what. Then I'd say sedation is way OK. But I'm not the one being sedated.

Question: does anyone have personal experience with sedatives? Do they actually help you feel better emotionally or do they just rob you of the strength to express emotions?

Cinquefoil

Specializes in Med Surg, Home Health. Has 2 years experience.

Just wanted to add that I will OFFER that hospice patient who may reject the cannula the O2 anyhow. And I will offer over and over again. I just wanted the hospice nurse's advice on what to do if/when the resident refuses care, as she tends to be very clear about what she does and doesn't want to do.

Ex: most of the time she will accept brief changes/peri care IF AND ONLY IF you find her already on the toilet or in bed. I remember one aide who is normally able to work well with her tried to get her in the bathroom via wheelchair and this sweet, spindly old lady went into full "we shall not be moved" civil disobedience mode - very sweetly but firmly saying "NO!" as she held on to the bathroom doorway with an iron grip.

Edited by Cinquefoil
clarity

What an interesting thread - I am a future student so this is an excellent discussion for me to read and learn from. My question is about who decides whether or not the patient is a danger, whether to self or others. If the doctor asks, "Is she a danger to herself?" And Trubie replies, "Her sats are X, she is removing her cannula, attempting to get out of bed, and is distressed, and we are not staffed to have someone sit with her on a continuous basis at this time." Then is it the doctor's responsibility to decide that the patient is a danger to self or is it the CNA-LPN-RN's place to make that value judgment? I have read so many threads on here about liability, etc that I wondered whose place it is to make that call.

itsmejuli

Specializes in Home Care.

I have an end stage dementia resident who refuses to eat or drink. Is refusing O2 really any different than refusing to eat or drink?

Gluteus Maximus

Specializes in Primary Care Nursing.

I'm under the impression you feel this patient is a danger to herself because she is desatting. Palliation means comfort measures, you shouldn't be concerned about her Sp02 as you should be about her agitation level. Chances are if she's comfortable, she will leave those NP alone. I can't believe your LTC does not carry an emergency supply of anxiolytics. Is this woman acting out because she's in pain? You really need to push for best practice and obviously your facility is sorely lacking.

canoehead, BSN, RN

Specializes in ER. Has 30 years experience.

You need meds for this type of situation on site. Anxious/confused people don't wait well.

If she is hospice comfort should be the big priority. Take off the O2 if she doesn't want it. Stop taking sats/vitals- they don't matter. Being a danger to self (moot point IMO) was not the issue, her agitation and discomfort was. The doc needed to step up and provide the meds. I would have stated "If I can give ativan for agitation, haldol for psychosis and benadryl for allergies I will try them each in turn for her agitation, but document the symptoms that back them up so you don't have to worry." Any confused upset person will do something you can document for all that. Bottom line; she wasn't comfortable...she needs help, and we can do it, we just have to pick and choose which behavior to document.

I am NOT saying to lie, just make sure the paperwork gods are satiated.

First I would be checking the res. chart to see if there was a Durable Power of attorney to verify who was responsible for making decisions for the res. Then there is the other factor that comes into play known as res. rights The Right to Refuse Treatment comes to mind here. After that I would assess the res. to make sure I was trying all the least restrictive measures, then keep documenting, why they didn't work, what other measures were tried. If the res. refuses oxygen they have this right, again then there needs to be documentation about what was done to encourage the use of oxygen as in res. education about the benefits of using it and the risks of not using it. I would also check to see if the res. has an advanced directive. If the res. is a no code no hospitalization, etc. and this is what the res. wants, the situation is covered. If a res. is a full code and it is determined that the SNF cannot safely care for the res, is not staffed for all of the intensive supervision this res. needs then I would be calling the DON, admin. or whoever makes these decisions about transferring the res. to a setting that would be willing to deal with all of these issues. If a person is a danger to themself then you have to call 911 and the police make a decision to take them out of your facility by force and to an ER for eval.

Here in NY the docs in LTC are watched closely as far as ordering Benzo's. So the doc may have been trying to see if he could legally justify the Ativan. Like others in the post I agree that Benzo's don't always work so well with this group. I also prefer Haldol or Seroquel. The patient may have been restless from the hypoxia. Also Benedryl can contribute to delerium with its anticoninergic properties, and Phenergan--not a good idea--could cause Akesthesia (inner restlessness) which would certainly not help an already agitated patient.

The pulling off of the NC could have been inadvertant due to cognitive changes but could also have been passive suicidal behavior--if the patient was with it enough to be taking it off on purpose. Here in NY all LTC facilities are not restraint free so using the soft wrist restraints is not an option.

Also is she sitting up as high as possible. If she had COPD or fluid in her lungs laying supine will be difficult for breathing. Is she getting any breathing treatments? You stated that her lungs sounded aweful so that could help. She isn't in CHF? Is she on lasix? Not sure how much was done at the hospital since they are moving towareds hospice. If they didn't do as much due to this there could be a lot that could be going on an possibly addressed with meds/tx.

Is she a risk to herself? Actively--no, passively maybe.

CoffeeRTC, BSN, RN

Has 25 years experience.

You need meds for this type of situation on site. Anxious/confused people don't wait well.

If she is hospice comfort should be the big priority. Take off the O2 if she doesn't want it. Stop taking sats/vitals- they don't matter. Being a danger to self (moot point IMO) was not the issue, her agitation and discomfort was. The doc needed to step up and provide the meds. I would have stated "If I can give ativan for agitation, haldol for psychosis and benadryl for allergies I will try them each in turn for her agitation, but document the symptoms that back them up so you don't have to worry." Any confused upset person will do something you can document for all that. Bottom line; she wasn't comfortable...she needs help, and we can do it, we just have to pick and choose which behavior to document.

I am NOT saying to lie, just make sure the paperwork gods are satiated.

Is she being covered by an actual hospice or just pallative care by your LTC. If she is on hospice, they should have been called and they could have gotten the meds faster.

As far as the 7 hour delay in delivery.....I totally understand that time frame, BUT that is unacceptable. Your pharm and facility should have a STAT delivery plan and/ or a back up for this service. Our reg delivery time is that 7 hr or "when ever it gets here" time frame but the STAT is 1-2 hrs

If she is pallative and has a DNR..you just need to do the best you can to keep her comfortable. If she's pulling of the O2 then it stays off for a while and you just reapply prn. I understand wanting to give her something to calm her down and let her rest.

ABH® cream does work wonders. It is the combo of them together. Benadryl alone doesn't always help unless it is at at least 50mgs

Esme12, ASN, BSN, RN

Specializes in Critical Care, ED, Cath lab, CTPAC,Trauma. Has 41 years experience.

Yes.....I believe she is in danger of hurting herself. Whether she was hospice,pallitive,or full code........she was in danger of hurting herself because in her dementia she could not make poper decisions to keep herself safe. Not that she was "purposefully" hurting herself she just lacked the judgement capabilities in the same way a 2 year old cannot make the decision to not run in to the road. In both cases they need to be protected from themselves. I am not sure why the MD was so focused on whether she was a danger to herself unless he was thinking about physical restraint. BUt someone should not be physically restrained without chemical restraint. You need to be careful about Haldol like drugs and the elderly/people with cardiac issues due to lethal arrythmias that can occur (IV Haldol) and tardive dyskinesia. BUt they do need intervention to keep them safe and calm. How sad that you don't have and emergency dose access for this very reason. Is there anyone on call that couold have been called by supervision? A shame that the family dictated her care for reimbursement purposes.....:confused: