Use of pulse oximetry in hospice

[HoosierMale]

As a novice to hospice care I have a question related to using the pulse ox with vitals. I could not recertify a patient owing to his 02 sat being too high for too long and have been getting the third degree every since he was disnissed as not appropriate. usually once a week or more I am assaulted with some remak abpout why a dying patient would ever need to have their pulse ox read. If you think he needs 02, just put it on I am told. No need to take a reading. A good nurse should not need a pulse ox as these patients are terminal and it is unncessary. I think some of this may relate to the fact that I asked for a finger tip pulse oximter and was told I would half to do without or buy my own. I have always used one and I thought the recert and admit process it would be helpful. Maybe this is about just not losing a potential patient. Any suggestions or was I told good info here?

[kids]

In the last 2 years I've worked for four different hospice facilities owned by 3 different entities. It was not the policy of any of the facilities nor of the 6-8 different Hospice agencies following the patients in them to routinely check SpO2.

I did ask about it and was told the patients SpO2 doesn't matter, O2 is prescribed and applied as a comfort measure. They were not going to put O2 on a comfortable patient because their number was low nor were they going to take it off of someone who was more comfortable with it on because their numbers were 'good' on room air.

I'm a little confused by your statement

I could not recertify a patient owing to his 02 sat being too high for too long

SpO2 is not an indicator of whether or not someone is terminal.

[HoosierMale]

Well that is good info which I appreciate. Sorry to leave you confused but I can understand. There is a specified lower limit for o2 sat in a dx of copd. I do not mean to doubt any info I am given but I believe that is one of the advantages of a web site like this where you can trust but also verify. Thanks for your comment!

[tommytwice]

I never use an O2 sat to tell me if a patient is comfortable........like said above, sometimes you'll have a very comfortable patient with a horrible O2 sat....and sometimes a very short of breath patient with a great O2 sat. I find that all the O2 sat really does is make the family anxious.....

Thas being said though, it does play an important role in recertifications. For pulmonary diseases Medicare guidlines require that O2 sat be less than or equal to 88%. So if we want our hospices to get paid in the future I think we will all be using O2 sats to help with pulmonary recerts.....

tommytwice

[AtlantaRN, RN]

our hospice issues each nurse a pulse ox. we use it for recerts for copd. also, on admission, or during time with hospice, a nurse may write an order to check sat each visit, apply 02 2-5L for comfort or to keep sat >88%. This is all well and good, but when you have someone transitioning and even with a 100% mask, you can't get the sat >80%, you rewrite the order for 02 100% mask for comfort prn. I already had a pulse ox because my hubby had a pe some years ago and is on 02 prn. they run about $90.

linda

[~MIA~, ASN, RN]

I purchased a brand new pulse ox on ebay for less than $50.

[templeknight7]

Hello All,

This thread seems to almost answer my query which has two parts :-

a) Does inappropriate or unnecessary oxygen therapy at end of life, (by this I mean O2 given in response to decreased saturation rather than distress), prolong a patients suffering ?

b) Can hypoxia at end of life actually contribute to a more peaceful and comfortable death inasmuch as I remember being told that the effects of decreased O2 saturation, as experienced by high altitude pilots, can lead to a sense of intoxication and even precipitate feelings of a spiritual nature before leading to unconsciousness and an advance into coma ?

[jlcole45]

Actually you can't just put someone on oxygen because you feel like it. You have to use

your critical thinking skills and ask do they really need it?

And one of the ways to assess this is with a pulse ox result - if its less then 90% or whatever the doctor or your facility states then your use the oxygen. Another question is do they look like the are in resp. distress? which would be another reason to apply O2. A couple of liters of oxygen will not slow down the dying process that much and it may make both the pt and family feel better.

[tewdles, RN]

Actually you can't just put someone on oxygen because you feel like it. You have to use

your critical thinking skills and ask do they really need it?

And one of the ways to assess this is with a pulse ox result - if its less then 90% or whatever the doctor or your facility states then your use the oxygen. Another question is do they look like the are in resp. distress? which would be another reason to apply O2. A couple of liters of oxygen will not slow down the dying process that much and it may make both the pt and family feel better.

I respectfully disagree...it is perfectly appropriate, in hospice and palliative care, to administer oxygen for comfort regardless of the pulse ox reading and generally without even checking the pulse ox. This decision is, as you noted, based upon critical thought and the primary goal is comfort of the patient. So...the lung cancer patient may have a pulse ox of 97 but have dyspnea, tachypnea, and anxiety....you can bet your boopy that I will have O2 on him lickety split followed by an opioid and benzo. Honestly, I added the pulse ox number just to make a point...I wouldn't even be tempted to actually check it in that scenario because the number is not significant actually...the patient's level of comfort is.

Oxygen at end of life might prolong the phase of active dying, but I am not sure that it has been studied and I doubt that it is measurable. Oxygen often does, however, improve comfort at end of life and that is the goal...comfort not speed or time.

No disrespect intended...just a big difference between ER and Hospice.

[missninaRN]

In both the current hospice I work for as well as the one I was with previously, we were not permitted to carry O2 sat meters.

As the post above mine explains, we will use O2 for comfort in terminally ill patients regardless of O2 sat readings.

And, as a very experienced hospice nurse explained to me, the knowledge that a loved one's sats are below normal can be upsetting to the family, but there really is not a lot we can do to raise low sats when someone is actively dying.

[marachne]

Just one comment about the use of oxygen and comfort. Yes, oxygen can contribute to someone's comfort, but oxygen therapy can also, in and of itself be very uncomfortable!

• There are some people for whom a face mask is extremely distressing -- they feel clostrophobic, they can't talk, etc.
  
• Oxygen without humidication dries out mucous membranes. This, especially combined with poor oral care can lead to irritation and contribute to mucosistis.
  
• masks, tubing, prongs can all cause skin iriritation and breakdown
  
• oxygen with humidification can increase pulmonary secretions/congestion
  

There are lots of components to comfort, and I think it is just as harmful to harrange a patient who is constantly taking off their oxygen (even if they are turning blue!) as it is to withhold it from someone whose O2 sats looks good but are in clear respiratory distress.

More arguments for critical judgment and patient centered care (and yeah, sometimes we're treating the family as much as the patient towards the end).

[ghillbert, MSN, NP]

Not a hospice nurse, but my mother is terminal and has home palliative care right now. Her sats sit around 94-96%, but she gets terrible SOB and when they did an ABG (to see if she qualified for home oxygen), her pO2 was only 52. So sats don't always = need for O2.