Severe Hypoglycemia before Death?

[sundowners2]

Not too long ago I took care of a dying patient (DNR). He was severely hypotensive even with norepinephrine and vasopressin (both maxed out) and dobutamine (5mcg/kg/min, set rate). The interesting thing was that for the entire shift he was also severely hypoglycemic. BG's ranged from 12-30's. An amp of D50 would only bring his BG up for a short time. This was especially strange in light of the fact that the day before his BG was very high.

He was on continuous TF. He was not tolerating the TF, residuals >200. At first, I attributed this to shunting of blood away from GI system due to the NE. This lack of enteral sugar might have caused the hypoglycemia, but I also wonder if this is part of the dying process... Anyone else have a similar experience with a dying patient?

[Mulan]

If he was dying and DNR, why was he on all that crap? They should have stopped all of that, in my opinion, and let the poor guy die in peace.

[BrnEyedGirl, BSN, MSN, RN, APRN]

Holly cow,..pressors, tube feeding and accu checks on a dying DNR,...that's just mean.

[pagandeva2000, LPN]

Was the patient a DNR? If so, then, I think they were wasting their time. If not, and this was an unexpected occurance, then, I guess they were trying to save his life. Sad, I know...

[pagandeva2000, LPN]

Made a mistake...I misread-I see he was a DNR. Sorry about that. I can't see why they wasted their time.

[blondy2061h, MSN, RN]

DNR doesn't in and of itself mean comfort care only.

We had an interesting case somewhat recently where an older gentleman with several health issues, and a poor prognosis, who was a DNR (but not comfort care), and VERY stable at the time (good bps, no pressors, walkie/talkie), had a routine blood draw that came back with a glucose of 30 mg/dL. He wasn't diabetic or on any drugs that would lower glucose and had good PO intake and an unrestricted diet.

We treated the hypoglycemia with juice, his glucose came back up upon recheck, and 30 minutes later he just suddenly died. There was no sense of impending doom or anything that would indicate he was about to die. It was just weird.

[strugglingnurse]

DNR does not mean do not treat. It simply means "do not resuscitate"- meaning no CPR and intubation.

So if pressures drop- you must treat it appropriately- i.e. fluids, drips... same with glucose.

Comfort care measures is different. In this case, I would have called our palliative care team and discussed with the family/ HC proxy the options- of continuing to stick the pt for glucose levels... untill he dies, or simply withdraw care. If the family agrees to comfort care, than I would start the pt on a narc. drip and and stop treating the blood glucose.

But to answer your questions, no I have not seen this hypoglycemic reaction prior to death.

[sundowners2]

Thanks, Blondy, for being the only one who addressed the question at hand rather than criticizing the care we provided for my pt.

Can any of you other posters think of a situation in which a full DNR would be on pressors? Like, for example, if he was already on the pressors before the DNR decision was made... In this case, the gtts would have to either be successfully weaned or Withdrawal of Care orders would have to be signed, which are completely different from a DNR order.

Also, since when do we not do BG checks on DNR pt.'s? DNR does not = comfort care.

Sorry if this post sounds harsh, but it's difficult for me not to take the "mean" and "wasting my time" comments personally.

[leslie :-D]

hypoglycemia is not associated with dying.

it is indicative of a disease process, however.

it can happen with certain types of cancers, hormonal irregularities, and even renal/liver/heart failure.

obviously he was a very sick gentleman and any s/s would be r/t to his pathology, and not his dying.

leslie

[pagandeva2000, LPN]

Thanks, Blondy, for being the only one who addressed the question at hand rather than criticizing the care we provided for my pt.

Can any of you other posters think of a situation in which a full DNR would be on pressors? Like, for example, if he was already on the pressors before the DNR decision was made... In this case, the gtts would have to either be successfully weaned or Withdrawal of Care orders would have to be signed, which are completely different from a DNR order.

Also, since when do we not do BG checks on DNR pt.'s? DNR does not = comfort care.

Sorry if this post sounds harsh, but it's difficult for me not to take the "mean" and "wasting my time" comments personally.

I apologise, especially since I have not dealt with DNR patients where so much intervention is done. Maybe I should have been more specific in my response, but allow me to say that I am not criticizing you for following orders or protocol.

[sundowners2]

Holly cow,..pressors, tube feeding and accu checks on a dying DNR,...that's just mean.

What would you have done with these things?

Would you have stopped the pressors (which would have almost certainly

killed the pt)?

Would you have stopped the TF? What part of DNR= no tube feeding?

Would you stop checking BG? Again, since when does DNR= don't treat

diabetes?

[Turtle in scrubs]

We often have pt's that we treat aggressively who are DNR. Usually it is not for very long - either they respond & get better, or more often we change their status to comfort care.

I recently had a pt whose rhythm and rate we couldn't control with cardizem and labetolol gtts. Family decided against cardioverting and finally opted to go the route of comfort care. I think it is often a process - trying to see if anything will work, and then deciding when to call it quits.

Now... as for the hypoglycemia. I only recall seeing this once. It was a pt who was a near drowning. At the end everything seemed to go whacko - we couldn't get control of his HR, temp, glucose, etc.