Rapid response

[Calm and collected]

Okay- I have a question for my very highly educated fellow nurses. I took my 98 year old father to the ER 10 days ago for respiratory distress. He was previously ambulatory, able to walk with a rolling walker, alert and oriented x4. He had severe wheezing and experiencing respiratory distress. He was recently diagnosed by cardiologist with CHF and pleural effusion

He was admitted for PNA and tx with abt. I brought his DPOAHC with me that clearly stated his wishes for DNR but comfort care okay. As a recently retired hospice RN, I would not have even taken him to ER except that he was experiencing severe resp distress I could not manage at home with SVN treatments. I wasnt able to get home 02 delivered from Apria even though NP ordered it for documented CHF and wheezing on minimal exertion. This was over 2 weeks of trying.

He was admitted, WBC 3.5, blood and sputum cultures negative. He had a DNR bracelet on and orders were clear for comfort care, I actually met with hospice evening before to set up care and take him home in next day or so, Before I arrived at his room the next morning, they called a rapid response as he was wheezing and in distress. Basically they gave him albuterol SVN tx and steroid IV. I walked in as they were stabilizing him. Bottom line is I took him home on hospice care with MS and ativan and 02 in place and he died after 3 days very comfortably. I think he had COPD even though he quit smoking in the 1960's but he had been having some mild wheezing easily managed by inhalers before moving in with me a few months ago. It had progressively worsened over the past few months.

My question? Why did they call a rapid response on a clearly documented DNR patient? I am not blaming anyone and no real harm done but I really am asking if this is what happens. Please don't take this wrong- really just want to know what is expected.

[Davey Do]

23 minutes ago, Calm and collected said:

Why did they call a rapid response on a clearly documented DNR patient?

Because he was "wheezing and in distress"?

The intervention made his living more comfortable.

It is good to hear your father passed on comfortably, Calm and Collected.

[MunoRN, RN]

"DNR" only applies once a patient has already gone into cardiac / respiratory arrest, so those treatments would still be appropriate. But you also stated the patient was 'Comfort Measures Only', which would have contraindicated the albuterol and steroids (and the home O2 by the way).

The appropriate Tx would have been repeat doses of morphine until the respiratory distress was adequately resolved.

[TheLastUnicorn]

DNR doesn't mean do not treat. Neither does Hospice, or Comfort care. If a patient is in distress they are clearly not comfortable.

DNR aside; Unless he was specifically ordered comfort measures only (to which nothing but oxygen, Ativan and morphine would have been prescribed, and despite a rapid response, nothing else would have been ordered assuming one was even called to begin with) he still would have received emergent care; its no different than what you yourself did. He was in distress.. You took him to the ER. He went into distress again, they called a rapid.

Comfort care, hospice, and being a DNR doesn't mean standing by and letting a patient suffer in a state of panic and distress.

[Calm and collected]

Thanks everyone for your comments.

[Rose_Queen, BSN, MSN, RN]

12 hours ago, MunoRN said:

(and the home O2 by the way).

Actually, home O2 is indeed allowed as a comfort measure. Not to treat low sats but to aid in reducing air hunger.

[Rose_Queen, BSN, MSN, RN]

12 hours ago, Calm and collected said:

My question? Why did they call a rapid response on a clearly documented DNR patient? I am not blaming anyone and no real harm done but I really am asking if this is what happens. Please don't take this wrong- really just want to know what is expected.

First, my sympathies for your loss. To answer your question, as others stated, the DNR did not yet come into play and truly relieving discomfort.

[MunoRN, RN]

6 minutes ago, Rose_Queen said:

Actually, home O2 is indeed allowed as a comfort measure. Not to treat low sats but to aid in reducing air hunger.

Although it's a common misconception, supplemental oxygen doesn't relieve air hunger since hypoxia isn't the cause of air hunger. It does however take away some of the more pleasant aspects that naturally occur in the dying process, making it an inappropriate treatment at the end of life.

[brownbook]

2 minutes ago, MunoRN said:

Although it's a common misconception, supplemental oxygen doesn't relieve air hunger since hypoxia isn't the cause of air hunger. It does however take away some of the more pleasant aspects that naturally occur in the dying process, making it an inappropriate treatment at the end of life.

I'm not trying to argue. But I wonder how researchers can evaluate if oxygen, "takes away some of the more pleasant aspects that naturally occur in the dying process"? How do they know if the patient died pleasantly or not?

[TriciaJ, RN]

When my MIL was dying of lung cancer, she had supplemental oxygen available to her even though she was on hospice.

I never saw her short of breath, but often she requested and used the oxygen. I mentioned this to the hospice nurse and he was unconcerned about the use of oxygen without SOB. I believed it was there to provide subjective comfort and seemed to supplement the morphine and lorazepam she was receiving.

[MunoRN, RN]

16 minutes ago, brownbook said:

I'm not trying to argue. But I wonder how researchers can evaluate if oxygen, "takes away some of the more pleasant aspects that naturally occur in the dying process"? How do they know if the patient died pleasantly or not?

The effects of hypoxia are initially a euphoria / intoxication followed by drowsiness and then sleep.

[MunoRN, RN]

8 minutes ago, TriciaJ said:

When my MIL was dying of lung cancer, she had supplemental oxygen available to her even though she was on hospice.

I never saw her short of breath, but often she requested and used the oxygen. I mentioned this to the hospice nurse and he was unconcerned about the use of oxygen without SOB. I believed it was there to provide subjective comfort and seemed to supplement the morphine and lorazepam she was receiving.

Trying to convince someone that dyspnea doesn't result from hypoxia can certainly result in far more arguing that is worthwhile at the end of life, and the placebo effect can be worthwhile if someone believes the misconception that strongly.