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.
While I agree DNR doesn’t mean do not treat, in this case, if the patient was truly comfort measures only, a rapid should not have been called, nor should breathing treatments given. If he was wheezing, meds should have been ordered to help with the comfort of breathing.
I think someone panicked and didn’t read the chart.
DNR doesn’t mean do not treat. He was in distress and needed immediate intervention to make him more comfortable. If his heart stopped or he stopped breathing on his one, a code blue would not have been called. I am glad he was able to pass comfortably, sorry for your loss.
* If he had medications available to help with his breathing (morphine, Ativan, etc.) I would personally give those instead of calling a RR and see how he responded. If I couldn’t get in touch with the MD promptly and didn’t have meds ordered I would call a rapid to ensure he is comfortable.. I would make the team aware that he is comfort measures only but I can’t watch a patient struggle and not intervene.
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?
Just venturing a guess, but maybe it's the increased co2 causing increased lethargy and sedation, but helping to clear that co2 and supporting ventilation you're preventing that.
Specializes in Surgical Specialty Clinic - Ambulatory Care.
15 hours 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.
That all may be true, but oxygen is often given at end of life care. It relieves the psychological distress of family seeing their loved one struggle to breath. But as far as the OP’s question goes, I think comfort care in a hospital is a hard thing to accomplish. To much liability. Plus, how old of a nurse was the one who called the rapid response? Rapid responses are to get a quick second opinion of a concerning situation. They are a great resource for nurses to ensure that the patient is safe and proper care was being administered. Now I would bet MOST hospital employees are not familiar with hospice and comfort care only measures. So I can see where steroids and albuterol would make the patient appear more comfortable to staff and thus they would consider it a reasonable action.
We get CMO patients with frequency at my hospital. But, a patient who is talking to hospice or a patient who is going home on hospice tomorrow or someone who is just DNR/DNI/do not escalate care is not the same thing as a CMO patient. It is a separate designation with separate orders. That sounds like splitting hairs, but we work in this grey area all the time, sometimes because it is the choice of the patient/their family, and sometimes because the decision is still fresh and has to go in stages for everyone's comfort. I would not call a rapid on a true CMO patient.
They probably called a rapid for the same reason you took him to the ER and allowed him to be treated: because he was in distress. If nothing else it got the therapy started quicker.
It seems to me that it wasn't clear to the team that he was CMO, which should have included orders for sedation for respiratory distress rather than any medical treatment.
I dunno, as an asthmatic I’m pretty uncomfortable when I’m wheezing. Strike that, I’m really really really uncomfortable when I’m wheezing. Try running around the block then plugging your nose and breathing through a coffee stirrer...it isn’t much fun. An Albuterol nebs is treating an uncomfortable symptom. I would consider it a comfort care measure.
Calling rapid response is appropriate for DNR patients with comfort care measures. The goal is palliative and NOT " curative. Relieving the dyspneic episode of your father FAST was the objective to the rapid response team. Switching gears, I am sorry for your loss.
LovingLife123
1,592 Posts
While I agree DNR doesn’t mean do not treat, in this case, if the patient was truly comfort measures only, a rapid should not have been called, nor should breathing treatments given. If he was wheezing, meds should have been ordered to help with the comfort of breathing.
I think someone panicked and didn’t read the chart.