Unmanageable COPD situation----HELP!!!!!!!!

tewdles, RN · Apr 8, 2010

70+ yr old patient, lives at home with daughter, who is also an alcoholic. Both smoke 3+ packs of cigarettes/day......
Situation is, he smokes a cigarette, then has an albuterol treatment........then the man has a panic attack because his heart rate is through the roof......educate to use 20mg roxinol and give him his ativan 1mg po/sl q4h----ativan is scheduled. We have been dealing with this for several months................the patient is going through 1 BOX of albuterol in a day and 1/2!!!!! it is a 7 day supply!!!!!! he calls our office, and my manager tells the nurse, "take more albuterol....." my thought is he will have an MI!!! his problem is he FEELS short of breath, and his sat will be 94-96% on 3-4 liters, but he is ANXIOUS from all the albuterol.
Frankly, i dont think it is appropriate to just DELIVER more and more albuterol.........drug book says via neb q4h, not after every cigarette---essentially the man is getting 60 doses of albuterol a day if he is smoking 3 packs of cigarettes daily............
We wouldn't just blindly deliver a 7 day supply of oxycodone or the like DAILY if that is what the patient is using, compounding the problem is the patient and daughter are most always altered.........(there was a 4 day period at the end of last month when they ran out of money and the store wouldn't take a check because they had bounced too many checks, so they went 4 days without alcohol-----frankly, we were worried he would start to go through dt's---i don't know how they made it to the first without an er trip for dt's)
I don't know what the answer is. We have begged and begged for him to be discharged because they won't follow the plan of care, I did stay one evening for 4 hours, demonstrating and having them return demonstrate and verbalize the rational for using ativan for anxiety and roxinol to decrease the workload of the heart---granted it was during that 4 day "coherent" non altered period.
the case manager and myself and the other call nurse are at our wits end.
thank you for your input. Social worker is involved, but this has gone on for at least 3 months and it is getting worse.
AtlantaRN

There are a number of questions which crossed my mind when reading your post. First...these can be extremely challenging cases and it is not uncommon for them to be discharged and readmitted to other agencies for noncompliance issues. So, good luck in helping this unfortunate patient.

I wonder if this man is on a steroid routinely? His smoking certainly creates inflammation which is probably what he is trying to relieve with the albuterol. Is addition of ipatroprium to the NMT an option? That might improve the effectiveness of the NMTs.

Is he on an antidepressant? Something like citalopram (or similar) may help control his overall level of anxiety and depression.

Is he taking a long acting opioid? Often these folks do much better if they are taking MScontin or similar and using the roxanol only for break through symptom relief.

Is this guy on a sleep aid? Many times these folks sleep VERY poorly at night which contributes to their inability to cope with their symptom burden during the day.

I feel your pain AtlantaRN. As hospice case nurses we tend to take it very personally when we are unable to help our patients experience an improved level of comfort and quality of life. It is difficult to make repeated visits and field call after call from patients who are resistant to changing their behavior in order to have a more comfortable life. Over time, these cases take a toll on our ability to maintain an appropriate and compassionate perspective in providing care. Often, hospice agencies are not able to provide us the emotional support we need to care for these people day after day which leads to burn out in the field.

I hope you are able to find a way to help this family. It is important to remember that we cannot fix those psychosocial things that are broken, cannot eliminate the substance and alcohol abuse, cannot require these people to quit smoking, etc...but we can often improve their lives somewhat with persistent caring and attention.

Good luck...and let us know how it is going with this patient.

allnurses Guide · Apr 9, 2010

That is a tough one- hoping to see more responses as the subject of hospice and/or rehab services with chronically non-compliant patients is such a challenging problem.

AtlantaRN, RN · Apr 11, 2010

tewdles, yes to all your questions, 30mg prednisone daily...prozac for depression, mscontin 30mg bid long acting opiod, temazepam 30mg qhs.......his main problem was anxiety/panic......he had been discharged from two other hospice agencies for noncompliance.....

note, i speak in the past tense......he was found lying next to his scooter with the neb mask on his face the night after I posted the original post.....dtr went to rehab that day....it was a bad, bad situation and all the nurses were just at our wits end with this one.........we could teach and teach and teach and as they were altered (except for that 4 day window), they were essentially unteachable......such a sad situation.

heron, ASN, RN · Apr 11, 2010

Hugs to you, AtlantaRN ... one of the hardest things to take in hospice is the fact that we can't make all our patients' deaths calm and peaceful, no matter what we do. With the severe substance abuse going on, the only way to control the albuterol abuse in particular would be inpatient placement.

The best you can do is all you can do.

allnurses Guide · Apr 12, 2010

Kudos to you AtlantaRN. Thank God there are so many more families that do not engage in the frustrating behavior, but you care enough to still seek answers here knowing full well there wasn't going to be a heck of a lot you could do. I think if I should change from the job I do now I would fit well in hospice, and I read a lot about it both from the nurses and the patient's perspective. This family likely took decades of abusing their bodies to get to the state they are (or were in the case of the man).

Honestly, it boggles my mind that the man was giving himself an albuterol treatment after every cigarette up to 2 packs of cigs and 60 albuterol treatments!! All the toxins in the cigs, then albuterol and alcohol, too? Just out of curiosity, was the man's doctor of a mind to let him use as much of the bronchodilator as he wanted to?

mariahas4kids · Apr 12, 2010

Just out of curiosity, was the man's doctor of a mind to let him use as much of the bronchodilator as he wanted to?

I too, am interested in what the doctor thought. I know that I had a patient in our care center (we have a 12 bed in-patient hospice facility) that had COPD so bad she couldn't walk, so she would bring herself out the the nurses station by wheelchair, ask for one of her cigarettes and her lighter (we kept them with her medications) then take her oxygen off and go to the smoke shack to smoke. Then she would come back in and ask for roxanol because she couldn't breathe. Q4, on the dot, she was on that call light wanting to know if it was time for her albuterol and MS treatment. :confused: Yep, she too was on every COPD med you could think of. The doctor wouldn't increase her albuterol, but we could increase the amount of MS we put in her neb tx.

AtlantaRN, RN · May 3, 2010

the doc wasn't allowing patient this much albuterol..........patient was obtaining from hospice, and when he would run out, his daughter would call and say "well, i'll have to call 911...." to which clinical manager would instruct nurse on call to deliver more. I was opposed to this as my thought was "we wouldn't do this with opiates........" It was a bad situation all the way around. he should have been discharged because he wasn't compliant, and it was a long --ongoing problem.