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?

[BrnEyedGirl, BSN, MSN, RN, APRN]

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?

I apologize if that sounded critical,..it did,.I see that now. The experiences I've had with DNR's over the last 10 years have just been very different. Most of the DNR's I've had the pleasure of caring for were patients with end stage cardiac disease. These pts had been ill for a very long time and available treatments were no longer helping.

These pts were not placed in the ICU and titratable drips were discontinued. The meds we did use were more for comfort not cure. For instance CHF pts would often get large doses of lasix if it helped their breathing, and of course we used pain meds prn. Perhaps the pt's I care for are at a different stage of the dying process than the pt you are speaking of.

Again I apologize for my previous post,..I obviously didn't put much thought into it, and in no way meant to offend anyone.

[lsyorke, RN]

If the patient was on oral diabetes drug, those effects can last for 72 hours after the last dose. Stopping the TF would result in low blood sugars that would only temporarily be reversed by bolus glucose.

[CHATSDALE]

i have treated patients, who when they came into the hospital were always designated as DNR but they were always given appriorate care for the crisis they were in until they were stable

even DNR patients are not at the point where they can be placed in hospice situations [ie with 6 months or less expected]

the level of care is somehting that has to be decided with md, patient and family

in a ltc setting you have residents that are DNR for a year or more but this has to be reassessed and reordered per md at certain intervals

[CoffeeRTC, BSN, RN]

Um....most of my LTC is DNR....I'd be out of a job if we didn't treat them.......

Yes....I've encountered the same thing (no pressors or tube feed). Come to find out the lady had underlying CA with mets everywhere (why that was left out on the admission paperwork is a whole other thread). She had a wound that was infected and looking like she was septic or getting that way. Blood sugars were in the low 40s even after all the injectables that I had in house....finally her sugar just bottomed out.....Many family issues and the DNR issue......

I've seen sever hypoglycemia at end of life with the cancers and septic pts.

[mpccrn, BSN, RN]

we often find ourselves working harder on DNR patients. as posted several times before, DNR and comfort care are not the same. i haven't seen severe hypoglycemia too often in the circumstances you have described but theoretically it is possible if the underlying disease process supports it.

[Mulan]

we often find ourselves working harder on DNR patients.

Just curious, what kind of results do you experience, do most of them bounce back or do they die anyway?

[leslie :-D]

Just curious, what kind of results do you experience, do most of them bounce back or do they die anyway?

great question, mulan.

leslie

[chenoaspirit, ASN, RN]

I agree that hypoglycemia is usually indicative of disease processes, lack of glucose in diet or IVF's, body's inability to carry/transport glucose effectively, etc. I dont know how it would occur normally with dying process. Treating DNR is so controversial. At our hospital when I call a doc regarding a patient, the first question I get is "Is this patient a DNR" and that really bothers me. They tend to do nothing when a patient is DNR. In my opinion, DNR means to treat effectively and actively, but when/if the time comes to intubate or perform CPR...THEN the treatment stops because that is ultimately what DNR means. It really does not mean do not treat. But it depends on what the family's decisions are at the time also, what they are wanting done/not done. When I have a DNR patient, I dont focus on that, I focus on the patient. Unless they are comfort care only, I still check BS and still treat hypo/hypertension. If they are terminal and actively dying, I may be less aggressive somewhat for patient comfort and dignity, but I also discuss with family about changing status to comfort care so the patient can die in peace. If the patient is oriented, of course its up to the patient unless they have designated a power of attorney to make those choices for them. Im in the middle of a "mess" at work right now with a patient with end-stage Parkinsons. She appears to be nonresponsive to physicians, but Ive seen her with her husband, she smiles at him, puckers to kiss him. He is so torn with the decisions he has to make and my heart aches for him and for the patient. She is otherwise healthy, but she cant swallow. The husband wants TFs because he cant justify in starving her til she dies. The doc refused to agree with TFs because she said she first "can cause no harm" so she called an ethics meeting. In the end, we inserted a dobhoff and started TFs. She appears now to be resting better. I saw his point and I saw the docs point, it was (and still is) a tough decision to make on both sides. I think its different with each patient, depending on diagnosis, prognosis, etc.