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.
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.
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.
Actually treating the patient's dyspnea would be a much better alternative to trying to trick the family into thinking it's been treated., particularly since the patient is still your primary obligation.
The rate of progression of the different processes that occur in the dying process have varying timelines, but when the hypoxia and hypercapnia components align in an optimal way, altering that to reverse the natural hypoxia is more harmful than beneficial.
Dyspnea results from hypercapnia and/or a sensation of physically constrained ventilation, hypoxia by itself does not produce dyspnea, it results in a decreased sense of awareness which includes a decreased sense of dyspnea. Artificially keeping a patient's oxygen levels higher than they would be otherwise, which then results in an increased ability to sense suffering, is not good practice, however common it may be.
Specializes in Surgical Specialty Clinic - Ambulatory Care.
2 hours ago, MunoRN said:
Actually treating the patient's dyspnea would be a much better alternative to trying to trick the family into thinking it's been treated., particularly since the patient is still your primary obligation.
The rate of progression of the different processes that occur in the dying process have varying timelines, but when the hypoxia and hypercapnia components align in an optimal way, altering that to reverse the natural hypoxia is more harmful than beneficial.
Dyspnea results from hypercapnia and/or a sensation of physically constrained ventilation, hypoxia by itself does not produce dyspnea, it results in a decreased sense of awareness which includes a decreased sense of dyspnea. Artificially keeping a patient's oxygen levels higher than they would be otherwise, which then results in an increased ability to sense suffering, is not good practice, however common it may be.
Interesting information. But I would say this is often a missed education for hospital staff...nurses and physicians. End of life care is not a common practice in a hospital. I worked at several in several states, I didn’t meet a nurse with ANY hospice or CMO measure experience until I started home care. I’ve been in home care for 2 years and due to the fact that I don’t do hospice I’m still not given any education on it. Anyone can scream to the heavens as much as they want about what is good practice vs what is common practice, but without the institutionalized education, good practice will not be what is done. Even knowing what you have said, I would still use oxygen if that was the order given to me from the MD. I have no qualms about speaking up, but I‘M still ultimately going to do what is ordered. I need employment for another 30 years.
I share this as a current hospice RN case manager. To clarify, a rapid response is not the same as calling a code. And since it can fall into the same lines as respiratory distress if someone is choking to death, a DNR does not prevent someone performing the Heimlich maneuver or similar if the choking is caused by an object which can be expelled.
I take care of a number of patients with lung cancer, and from a point of view when families call our 24x7 number with the expectation for a nurse to come out for respiratory distress, it's similar to a rapid response (granted, in our geographic area, nowhere near as fast as anyone would like given rural home environments typically off the beaten path.
Thanks to all for your comments and condolences. I have been busy with plans to lay my WW2 vet dad to rest with military honors.
I now realize he was in a gray area when rapid was called. The nurse who callled was in her late 20's I would guess. I took him home that day and the steroids did give him a "little bump" so he was able to easily tolerate the 25 minute ride home. I was just seeking input from this great resource we enjoy here.
As a recently retired hospice RN Case manager, I often would provide 02 in the home in response to family concerns, to give the family " something to do" when they would call the office in a panic as their loved one had a frightening ( to them) change in respiratory status ( found this could often prevent 911 calls instead of calls to hospice) or per patient request. Some were COPD pts who alrady were on home 02 sometimes for years.
Again, thanks immensely for all the helpful comments.
2BS Nurse, BSN
703 Posts
Exactly! That placebo effect! Give them the O2.