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The following is a scenario of a patient who was admitted for a COPD exacerbation for the third time this year. The patient, Kent Breeth, a 84-year-old male presented to the emergency department (ER) via ambulance on 4/5/18 around 1645, with severe shortness of breath and fatigue more than his baseline. Back at the SNF where paramedics assessed him, Paramedics stated, “he was breathing hard and heavy with cyanosis around the lips” , BP 145/89, HR 118, RR 24, Spo2 74% on 2L NC, and Temp 37.8C. 12-lead EKG showed sinus tachycardia with occasional PVCs. Patient was then placed on a simple mask at 6L and taken to the ER where care was then taken over by the ER nurse. On assessment in the ER, his vitals were BP 156/82, HR 115, RR 26, 82% on a simple mask at 6L, and temp 37.9 C. Neurologically, he was oriented to person, but was confused on where he was and the date. His pupils were 3mm and responsive to light. He appeared very short of breath, with use of accessory muscles, pursed lip breathing and very fatigued. He had bilateral crackles in the lungs and a barrel shaped chest. Skin was warm and dry to touch and intact with minimal bruising on the arms and clubbed fingers. Cap refill was >3 secs in all extremities. The remainder of the body systems were within normal limits.

While in the ER, respiratory therapy was paged, a STAT chest x-ray was done and labs were drawn. Chest x-ray showed congestion and hyperinflation. An ABG  was drawn and revealed Respiratory Acidosis with hypoxemia. At 1730 the daughter arrived and switched his DNR status to full code. Respiratory therapy was giving the patient albuterol treatments every 2 hours. The ER nurse administered  125 mg  solumedrol IVP and magnesium 2 mg IV. The patient was still having episodes of desaturation and was placed on high-flow nasal cannula at 40L. The patient was admitted to ICU.

In ICU the patient continued to have a significant work of breathing and was eventually intubated. Ventilator settings were set on A/C at 12, PEEP of 5, FiO2 50% and tidal volume at 500. Day one in ICU the respiratory therapist tried to decrease the Fi02 from 50% to 40% and the patient quickly desaturated to 83%. Patients daughter was updated on her father’s current status and a meeting was scheduled for the next day with the ICU team to discuss patients code status and next step in the plan of care. Day 2, the patient’s status remained the same and the daughter spoke with the ICU team to discuss code status and she agreed to have a father placed back to DNR and transfer to home hospice care to honor his wishes. Case manager set up home hospice, made sure there was a hospital bed, oxygen set up as well as transportation via ambulance back home. The patient was extubated, placed on NC at 6L and sent home on hospice. Kent Breeth passed away 5 days later with his daughter and family at his bedside.

Discussion Questions

1. If you were the nurse in this situation, how would you approach the daughters concerns with code status?
2. What client education would you give to a patient with COPD to prevent recurrent hospitalizatioins?
3. In this scenario, the patient declined rather quickly and passed away on hospice care. What resources would you provide to the family to cope with the loss of a loved one?