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

[DutchgirlRN]

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?

[chip193]

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

[chip193]

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

[Sheri257]

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

[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

[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...........

[shawng007]

actually, it doesnt matter what the end result is, the patient has the right to refuse, and as i said, NO means NO.

[ZippyGBR, BSN, RN]

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

[ZippyGBR, BSN, RN]

While this pt may normally function well with a low 02 sat; the description suggests she is decompensating. I'm a little confused by the concern that 'people die in the waiting room' and the statement that this 'wasn't an emergency'. As a side note; pt's are seen at the ED based on acuity, not mode of arrival. Calling 911 isn't going to get her in any faster, and is an inappropriate use of resources for nonemergency situations. While the medic's choice of words may not have been the best; the actions were standard of care for EMS.

yes given the clinicla picture of a a COPD patient on LTOT who is

- febrile

- SpO2 lower than usual

- more wheezy that usual

that starts ringing 'emrgency' bells in my head

[DutchgirlRN, ASN, RN]

An Update:

This patient did have a DNR in the home. The pt was put on a vent with his/her permission as a temporary measure to get the CO2 down.

My agency did not report the paramedic because I asked them not to.

When the ambulance radio'ed the ER that they were in route the ER doc gave them a direct order to turn the 02 down to 2L BNC, stating that he knows this patient very well.

The family won't be suing. They knew the patients lifespan was less than 6 months. They just wanted their loved one to be comfortable and be cared for respectfully.

[Sheri257]

actually, it doesnt matter what the end result is, the patient has the right to refuse, and as i said, NO means NO.

But there's all kinds of exceptions to that rule. If the patient is on drugs, alcohol, etc. ... or they've stroked out ... or they have head trauma, Alzheimer's, etc. The list goes on and on.

If the situation involves mental impairment where they're not competent to make decisions even temporarily then, no doesn't mean no. And there's lots of research documenting cognitive impairment as a common phenomenon in chronic hypoxic COPD'ers.

:typing

[cardiacRN2006, ADN, RN]

i if that were my family i would sue, and i guarantee i would win too.

No, actually, you wouldn't. You are not familiar with a paramedics' protocols.

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.

This thread wasn't about practicing nursing at all, it was about prehospital.

[fr.dad]

There are a number of factors being ignored or getting too little discussion in this thread.

1. This pt [not some hypothetical text book pt, some other pt with a different set of circumstances who was treated in the past] does have a DNR in place. This pt does have a family member designated with a DPOA. Those facts have been established in earlier discussion in this thread.

2. This pt is, by DG's description, A&Ox3 and competent to manage her affairs. She has been eating, shopping on eBay, playing cards and conversing with family all day with a PO2 in the low 70's. The only reason the family called for the home health nurse was because they thought the O2 levels should have come up after breathing treatments and it was getting late in the day.

3. DG reported very emphatically several times that this was NOT AN EMERGENCY. Many posters here are looking at the PO2 levels and declaring an emergency in spite of the nurse's professional assesment. Then some are using that presumed emergency condition to justify overruling the pt's refusal and force treatment on her.

4. Calling 911 does not waive a pt's right to refuse treatment. Pt refusals are a common part of the ambulance business. They happen every day. There are other conditions that do activate "implied consent" such as unconsciousness, underage status, prior adjudication, obviously impaired mental status. According to DG's description of this pt, no such condition existed at the time of this incident. What happened later in the ED or the ICU does not change the pt's right to refuse treatment at the time of this incident.

5. Very little attention has been paid to assessing the pt's mental status, rather than assuming it without assessment. Nurses, Paramedics, and EMT's all receive training in assessing mental status. All should be using those skills, following those procedures as part of their decision process, rather than basing everything on what the meter shows. Many here are arguing for actually disregarding the patient's mental status to overrule her refusal of high flow O2. That is bad medical practice, whether pre-hospital or not.

6. No one else has asked why the DPOA was not invoked by the family too address the presumtion of pt incompetence. If the pt is not competent to refuse the high flow O2, then the DPOA becomes effective and the Attorney-in-Fact is authorized to refuse on the pt's behalf.

Fr.Dad