So what if one day you go into work on your med/surg floor and have a pt that has sats of 87% on NC 4L. You check everything, place a mask, call the MD with no results, call respiratory, respiratory changes to a non rebreather (still with minimal results), call a rapid response, MD places bipap (with good results),.....then after everyone leaves, pt decides they don't want oxygen anymore because they are end stage emphazema? This pt refuses all O2 at this point and you explain that they will die today with out oxygen. The pt states they are aware. (pt is AO4) Pt then signs a DNR (yes, during all of this they were a full code:uhoh3:), but refuses hospice. MD, charge nurse, nurse and respiratory explain to pt that without any oxygen pt will die today. Pt states understanding to everyone. WHAT WOULD YOU DO?
I am having second thoughts about how I handled this after talking with a coworker, but still feel that what I did was right since I followed the patient's wishes. I documented everything and offered several times oxygen, morphine and ativan for this patient, but pt refused everything. Pt refered to hospice the day before, but the pt refused. What would you do? One of my coworkers stated that she would placed the oxygen on the pt when they went lethargic from low O2 because otherwise was helping the pt comit suicide.
Sounds like you had a team approach, and everyone was on board, so job well done. The process can be time consuming, so kudos to you, as I'm sure it was stressful. But you did the right thing, everyone was on board. Sounds like you did a thorough job. For whatever reason, the nurse and doctor the day before should have had the DNR signed, but been there, done that. Discussions happen, and for a lot of patients and their families, they want a few days to think about it. I try to stress that the decision can be overturned at any time, but with end-stage lung disease, they may not be given days to think about it. If something happens, we assume full code status.
I would just be careful about the validity of AAO x 3 with a poor ABG. Don't know how well that would stand up in court.
And don't worry about your petty co-worker and her/his comments. They are a dime a dozen. Be confident in your abilities to assess the situation and give responsibility to those who should own it.
Specializes in Critical Care, ED, Cath lab, CTPAC,Trauma.
while there are some hospices that require their pts to be dnr, there are also many others that do not require this.
just an fyi.:)
leslie
Really? Interesting.....we all recognize that the patient is dying and that death is inevitable so services are set in motion to ease the suffering of the dying process because they are dying to allow death with dignity....with a code at the end. I have not run into this at all......ever. Interesting.........really......Thanks!!!!!!!!!:):heartbeat
So what if one day you go into work on your med/surg floor and have a pt that has sats of 87% on NC 4L. You check everything, place a mask, call the MD with no results, call respiratory, respiratory changes to a non rebreather (still with minimal results), call a rapid response, MD places bipap (with good results),.....then after everyone leaves, pt decides they don't want oxygen anymore because they are end stage emphazema? This pt refuses all O2 at this point and you explain that they will die today with out oxygen. The pt states they are aware. (pt is AO4) Pt then signs a DNR (yes, during all of this they were a full code:uhoh3:), but refuses hospice. MD, charge nurse, nurse and respiratory explain to pt that without any oxygen pt will die today. Pt states understanding to everyone. WHAT WOULD YOU DO?
I am having second thoughts about how I handled this after talking with a coworker, but still feel that what I did was right since I followed the patient's wishes. I documented everything and offered several times oxygen, morphine and ativan for this patient, but pt refused everything. Pt refered to hospice the day before, but the pt refused. What would you do? One of my coworkers stated that she would placed the oxygen on the pt when they went lethargic from low O2 because otherwise was helping the pt comit suicide.
This sounded like a good one to hash out on AN.
I'm curious to know what your assessment of the patient was. The way your post makes it sound like his sat of 87% set off this whole cascade of events. How fast was he breathing? Accessory muscle use? These type of patients can have a baseline of o2 sats in the 80's as their body has compensated over the years.
The patient doesn't want hospice, but sounds like he/she is ready to go and done with any type of treatment. You did everything you could and offered different treatments to make him comfortable. This is the patients decision and he decided he wanted nothing done.
Specializes in MED/SURG STROKE UNIT, LTC SUPER., IMU.
The O2 sat was mid 80s and resp rate was anywhere between 26-32. Anytime we have a pt that is sating less than 90%, we have to make a call to the MD on the med/surg floor. I knew why he was sating lower and RR higher, but still needed to let the MD know. I called the primary and the pulmonary, but did not recieve a call back from either one for an hour or so, in the mean time I called respiratory to help me work with him since we have so many patients on our floor and I couldn't just work one on one with him. Respiratory recommended we call the rapid since we couldn't get a hold of the MDs. At this point is when the rapid team came up and assessed that he needed a bipap. After everyone left, I just had a feeling that this guy was going to take off the bipap and if he did we had two options 1. do what I did and allow him to choose what he wanted with the paperwork in order or 2. wait until he codes and send him on his was to ICU to be intibated. I knew the pt did not want to be on a vent, but all the ducks were not in a row to avoid that unless I worked fast. He was a full code, he had no living will and the family was not at bedside and I couldn't get a hold of them at that time.
You could of restrained him while on the bipap. We do this for a few hours until family comes in to help. COPDers need several hours on a bipap to reverse a bad ABG. Did anyone do a Chest X-ray to assess for CHF/pleural effusions? Sometimes these patients get fluid overload in the hospital or a worsening pneumonia. Very treatable. Really your RRT should have been doing these things.
Specializes in Clinical Research, Outpt Women's Health.
Are y'all doctors or nurses? Seems to me that the doctor felt this patient was competent and acted appropriately and the nurse followed these orders and policy.
All this 2nd guessing and order this and order that is just plain silly.
Ok as a mental exercise I suppose, but not really all that productive in regard to the reality of the situation.
Restraining a patient deemed competent by their MD to force Bipap on them? Seriously?
As to amounts of MS. If that was the amount it took to prevent the patient from suffering air hunger then that is the amount that was needed and was not in any way "ending things early".
The arrogance of some people who wish to make others decisions for them amazes me.
It would be a very different situation if the MD had not deemed this patient competent and/or the nurse strongly felt the patient was not competent to make their decisions, but this was clearly not the case.
sometimes these patients get fluid overload in the hospital or a worsening pneumonia. very treatable.
yes pneumonia is treatable, but people have the right to refuse treatment. also, what kind of quality of life would this patient have? you treat the pneumonia, sure, but this is a dying man. i would not want to be hooked up to iv's, machines, etc, while i am dying. leave me be, dose me up with my morphine, keep me comfy, and allow a dignified death.
restraining someone so you feel better about their care is terrible, imho. they are dying, it is so undignified to die like that.
You could of restrained him while on the bipap. We do this for a few hours until family comes in to help. COPDers need several hours on a bipap to reverse a bad ABG. Did anyone do a Chest X-ray to assess for CHF/pleural effusions? Sometimes these patients get fluid overload in the hospital or a worsening pneumonia. Very treatable. Really your RRT should have been doing these things.
Classicaldreams
In your posts you really make the assumption this person has family that will come in and make these decisions. How many times have you seen patients in the ICU that have absolutely no family. They sit there for days/weeks/months with no family and no visitors. Restraining someone that has an altered MS and needs bipap is one thing. It is quite another to do it to someone that is mentally competent. This person is a patient, not a prisoner.
Sounds like there are a few posters in here who don't believe we have a right to die...
I was thinking the same thing. I'm sorry the patient refused Hospice. I do think the patient had a valid point. There were obviously a lot of treatment options to return him to stability and continued life. I maintain that death is not always a bad thing, letting nature take its course is not suicide. Comfort care is just that and Morphine, Atropine and Ativan are considered the treatment protocol for this situation. I think there is a time everyone becomes tired and ready to let go of life. The will to live is profound as any Medical person knows; if the patient says enough (or his advance directive says enough) I will listen. The Nurse who commented she considered withholding oxygen to be assisting a suicide, projected her beliefs onto his situation. I also know that Oxygen will not keep anyone alive, it might delay death and create more discomfort in the long run.
classicaldreams
101 Posts
TonyaM73,
Sounds like you had a team approach, and everyone was on board, so job well done. The process can be time consuming, so kudos to you, as I'm sure it was stressful. But you did the right thing, everyone was on board. Sounds like you did a thorough job. For whatever reason, the nurse and doctor the day before should have had the DNR signed, but been there, done that. Discussions happen, and for a lot of patients and their families, they want a few days to think about it. I try to stress that the decision can be overturned at any time, but with end-stage lung disease, they may not be given days to think about it. If something happens, we assume full code status.
I would just be careful about the validity of AAO x 3 with a poor ABG. Don't know how well that would stand up in court.
And don't worry about your petty co-worker and her/his comments. They are a dime a dozen. Be confident in your abilities to assess the situation and give responsibility to those who should own it.
Classicaldreams