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Do comfort care patients get oxygen?

Posted
quirkystar quirkystar (Member)

I had this patient who is actively dying and basically "comfort care" meaning treatment was stopped and measures to improve comfort are placed. If the patient's O2 is dropping from a previously >92% level, but is not showing any discomfort or respiratory distress, should I be hooking him up to oxygen? Hooking up to oxygen could be seen as prolonging the dying process, no?

SierraBravo

Has 3 years experience.

The only time I would put a hospice/comfort care patient on O2 via NC is to comfort the family if they request it. It's not doing anything because someone who is actively dying is likely breathing through their mouth anyways, and you're not going to put a mask on a comfort care patient.

RNNPICU, BSN, RN

Specializes in PICU. Has 13 years experience.

Depends on the situation. Sometimes just the flow of oxygen makes there breathing a little easier and can help them pass. I would always make sure you have orders that include administration of oxygen for comfort with parameters. When pts are intubated and have a terminal extubation, many times a NC with a few L O2 are used for comfort only, not meant to provide support. Using a non-rebreather would not be for comfort that would be providing respiratory support

melizerd, ASN, RN

Specializes in Med/surg, Onc.

Depends on your facility. When I have comfort orders they include O2 if the patient or family feels they need it. A liter or two on nasal cannula won't prolong anything.

hppygr8ful, ASN, RN, EMT-I

Specializes in Psych, Addictions, SOL (Student of Life). Has 18 years experience.

I had this patient who is actively dying and basically "comfort care" meaning treatment was stopped and measures to improve comfort are placed. If the patient's O2 is dropping from a previously >92% level, but is not showing any discomfort or respiratory distress, should I be hooking him up to oxygen? Hooking up to oxygen could be seen as prolonging the dying process, no?

It really depends on the exact language used in the POLST? Go to the chart and it will tell you what you need to know.

Hppy

Depends. Keep in mind too that just because oxygen is applied does not mean the lungs are perfusing in a comfort care situation. In certain end stage/MODs situations, the lungs are not capable of adequate gas exchange.

Tenebrae, BSN, RN

Specializes in Mental Health, Gerontology, Palliative. Has 8 years experience.

Comfort cares, does it have potential to provide comfort to the patient or their family

It would depend on the circumstances. If it was a patient in end stage COPD or lung cancer and had the potential to provide some measure of comfort (whether actual or perceived) then yes I would give them the o2 if it was charted.

I had another situation where the family were asking for it, it was not clinically indicated for this patients type of cancer and the doctor did not order it.

Its like using buscopan when patient is actively dying to address issue of secretions. Usually its more so the family can feel that their loved one is still taken care of than any actual benefit however we still give it if charted

marcos9999, MSN, RN

Has 5 years experience.

I definitely think O2 is a comfort measure. I would always leave the O2 at least 3L but some Docs don't think that way. So you have to follow Doc's orders no?

melizerd, ASN, RN

Specializes in Med/surg, Onc.

I definitely think O2 is a comfort measure. I would always leave the O2 at least 3L but some Docs don't think that way. So you have to follow Doc's orders no?

Call the doc and advocate for the patient. I'm in a hospital on an oncology floor. We do a lot of comfort/hospice care.

imintrouble, BSN, RN

Specializes in LTC Rehab Med/Surg. Has 16 years experience.

If the patient is comfort care, why are you doing VS? At the most we take those vitals daily. Not at all if we have a choice.

We try to dissuade the family if they request. Just because we're faced with personal ethical decisions.

I'd only put O2 on a patient if they were struggling to breathe.

An O2 sat is only a number. Look at the comfort care patient, to see if they're not comfortable.

ArtClassRN, ADN, RN

Specializes in Med Surg. Has 8 years experience.

If it makes the patient more comfortable.

I had this patient who is actively dying and basically "comfort care" meaning treatment was stopped and measures to improve comfort are placed. If the patient's O2 is dropping from a previously >92% level, but is not showing any discomfort or respiratory distress, should I be hooking him up to oxygen? Hooking up to oxygen could be seen as prolonging the dying process, no?

This is a good and common question.

The first thing I will answer is NO, adding oxygen is not likely going to prolong someone's dying process.

As mentioned, hospice professionals spend comparatively little time considering "numbers" when assessing their patients. We really don't care what the Pulse Ox is, or the blood sugar, or really even the BP most of the time. Sometimes we do but not always. Here is a question; why do you suppose numbers aren't that terribly important to us most of the time? When do you suppose that hospice professionals ARE interested in those type of numbers?

The answer to those questions really revolves around the philosophy and goals of care. We are focused with laser precision on comfort (what the patient wants, what the patient demonstrates, and what we advocate to them from experience and knowledge base). If the patient is dyspneic we treat that with O2 and both pharm and nonpharm nursing intervention. If the patient is actively dying we don't need to check their BP to know that they are dying, we expect the VS to be wacky. We don't need to check the Pox to know that it is going to crash and that we can't correct that. They are dying.

This is a very different mindset from the function of most nurses in most other settings.

We are not trying to "fix" anything in hospice. We are interested in palliating noxious symptoms. A falling pulse ox is not a symptom of discomfort, it is a symptom of organ failure that may or may not be uncomfortable.

I worked many years in critical care, emergency, and transport nursing. I was a master of numbers and the more ways we were monitoring patients and gathering numbers the happier I was. Fortunately, before switching to hospice I spent considerable time in community and public health. That experience caused me to learn how to talk with and listen to/hear what my patients were telling me rather than focusing on their numbers.

So, philosophy aside; the comfort care orders that were established for this dying patient should have included standing orders for oxygen and a pharmacological treatment for dyspnea, not for low pulse ox. As well, the comfort care orders should discontinue all labs, VS, other diagnostic procedures, dietary restrictions, etc. The patient ought to be allowed the things of comfort desired and defined by him/her within the confines of the law and visitation of family and friends should be encouraged and not limited in any fashion.

There was a patient I had in nursing school who was very old and and had COPD. She wanted to go home and die. She also wanted BiPap with oxygen, and that request was granted to her. As an asthmatic I can tell you that air hunger is a horrible thing to experience. If the dying person wants oxygen, let them have it. Also let them have a lot of pain meds and anxiety meds to get them through. The application of O2 will not prolong their life by very long- they will still die of their disease eventually but will be more comfortable through the process.

JBudd, MSN

Specializes in Trauma, Teaching. Has 39 years experience.

I had a pt we were admitting for comfort care, mostly nonresponsive. I left his 02 on just because.... no real reason other than he seemed comfortable and I didn't want to change anything. RT was unhappy with me when I started to send him to the floor with it on, and they removed it on arrival. Pt died in about 10 minutes, RT told me the 02 was the only thing that had kept him going. I think it was just his time.

I had this patient who is actively dying and basically "comfort care" meaning treatment was stopped and measures to improve comfort are placed. If the patient's O2 is dropping from a previously >92% level, but is not showing any discomfort or respiratory distress, should I be hooking him up to oxygen? Hooking up to oxygen could be seen as prolonging the dying process, no?

I doubt it prolongs the dying process, but seriously, what is the point? If the patient is actively dying, you shouldn't be monitoring VS anyway, so you wouldn't know the pulse ox was dropping. If the patient is unresponsive and showing no signs of air hunger, then placing O2 is unnecessary. In fact, the cannula on the face can be a noxious stimulus for some people. I'd have left it off.

Yes, 2L NC. It's part of the bundled order for comfort care/withdrawal of care which also includes morphine and Ativan.

KelRN215, BSN, RN

Specializes in Pedi. Has 10 years experience.

If the patient is comfort care, why are you doing VS? At the most we take those vitals daily. Not at all if we have a choice.

We try to dissuade the family if they request. Just because we're faced with personal ethical decisions.

I'd only put O2 on a patient if they were struggling to breathe.

An O2 sat is only a number. Look at the comfort care patient, to see if they're not comfortable.

I agree. In pediatrics, families are often so used to seeing their kid on the monitor all the time. It's hard for them to let that go. We would try to dissuade them from leaving the child on the monitor but, often, the parents wanted to see what was going on. So what we would do is leave them on the monitor but turn all the alarms off. No temps or BPs taken. Usually we could get the parents to the point where they'd be willing to take all monitors except the O2 sat monitor off. It still didn't offer much useful information- we saw kids whose sats dropped from 90s to 80s to 70s to 60s over days and others who did it in minutes.

O2 via NC isn't going to prolong anything. I don't see a problem with using it for comfort.

I just had this happen - it was sudden and the experience was traumatic to the family. It seemed to give them comfort that we were "doing something" to make the pt more comfortable beyond the standard meds. Honestly the o2 isn't really helping if the pt's circulation is shutting down and O2 isn't harmful and is usually left up to nursing judgement.