It is common for family members and caregivers who are not trained in end-of-life topics to be concerned about their loved one's oxygen concentration (SpO2 and sometimes also abbreviated SPaO2) reading from a pulse oximeter. Suppose their loved one refuses external oxygen or takes off the external oxygen. In that case, this often causes distress to the family and caregivers because they are focused on the numbers vs. the patients themselves. Hospice is about patient-centered care, and I would like to present four case studies to demonstrate how hospice manages this situation with compassion.
Case Study – 90-Year-Old Female on Hospice for Protein Calorie Malnutrition with a history of Congestive Heart Failure
The patient had increased trouble breathing at 91% on room air, refusing oxygen. They allowed hospice and the staff to start 10 mg liquid morphine every two hours as needed and 1 mg liquid lorazepam every four hours as needed. The staff gave the medications to the point they were routine within those time frames, and the patient was still uncomfortable. Even though their numbers were within the normal range of 91% to 100%, considering they had no history of COPD, they were not comfortable. The patient was ordered 2 liters per minute of oxygen therapy and shortly became comfortable.
Case Study – 78-Year-Old Male on Hospice for Congestive Heart Failure
They were 98% on room air, and they were going into respiratory failure. Keep in mind the number was 98%. I put three liters per minute of oxygen on them, and the patient was tripoding multiple times, trying to breathe. Tripoding is a natural human reaction to lean forward almost in a tripod position, which helps provide relief. His heart rate was 118 bpm, and he was verbalizing he couldn't breathe correctly. Within a two-hour timeframe, he received 40 mg of liquid morphine and 1 mg of lorazepam liquid, which barely helped. I could hear fluid in his lungs. I gave him the option as he was able to speak for himself as to whether to call 911 and go to the hospital to drain the fluid off his lungs (just before coming onto hospice services, he had a liter of fluid removed). The other option was that I could continue giving him the comfort medication with the purpose of palliative sedation, where we would put him into a comatose state to get him more comfortable starting the dying process. He decided to allow me to call 911, and they came 40 minutes later. EMS almost refused to take him because his oxygen saturation was 98% on 3 L, and I had to walk them through that he was in respiratory failure and wanted to go to the hospital for help. They were focused on the 98%, NOT the patient!
Case Study – 92-Year-Old Female on Hospice for Congestive Heart Failure
The patient was at 86% on room air. The normal range for somebody who does not have COPD is 91 to 100%. I did not rush to put this patient, who is 86% of room air, on oxygen! I looked at them, the person, and they were not struggling to breathe. I looked at them, the person, and their lips were not bluish. Even though they were doing mild belly breathing, considered accessory muscle use, they were not in any distress, so I updated their facility staff care team to do nothing. We do not treat the numbers! We treat the person. The person did not need oxygen even though their numbers were low. I did provide education as to how to determine when to give oxygen.
Case Study – 70-Year-Old Male on Hospice for Alzheimer's Disease
The patient was at 66% on room air (checked thrice due to the low percentage). The normal range for somebody who does not have COPD is 91 to 100%. I did not rush to put this patient on oxygen, who is on 66% of room air! I looked at them, the person, and they were not struggling to breathe. I looked at them, the person, and their lips were not bluish. They were not using any accessory muscles to breathe. I updated their facility staff care team to do nothing. We do not treat the numbers! We treat the person. The person did not need oxygen even though their numbers were low. I did provide education as to how to determine when to give oxygen.
Conclusion
The four case studies presented in this article underscore the importance of patient-centered care in hospice settings. They highlight that the focus should always be on the patient's comfort and overall well-being rather than solely on their oxygen saturation numbers. While these numbers are essential, they can sometimes mislead caregivers into prioritizing data over the patient's condition.
The case studies demonstrate that a patient's comfort and quality of life can sometimes be achieved without strictly adhering to the ‘normal' oxygen saturation range. For instance, a patient with a saturation level of 91% might still be uncomfortable and require oxygen therapy. In comparison, another patient with a saturation level as low as 66% might not show any signs of distress and, therefore, not require additional oxygen.
These examples remind us that each patient's situation is unique and should be treated as such. It is crucial to observe the patient's overall condition, including their breathing, coloration, and use of accessory muscles, rather than relying solely on oxygen saturation numbers.
The key takeaway from these case studies is that in hospice care, we should not treat the numbers; we should treat the person. This approach ensures that the care provided is patient-centered, prioritizing their comfort and dignity more than anything else.
