The benefit of routine oxygen for terminally ill patients who are near death

1. The benefit of routine oxygen for terminally ill patients who are near death Margaret L. Campbell, PhD, RN, FPCN Hossein Yarandi, PhD Wayne State University College of Nursing Detroit, MI

3. Oxygen benefits • Correct hypoxemia • Reduce dyspnea • Prolong life

7. Oxygen burdens • Decreased mobility • Nasal drying • Nosebleed • Feeling of suffocation • Prolongs dying • Extends caregiver days • Increases health care costs • Flammability risks

8. The benefit of routine oxygen administration for terminally ill patients who are near death • Aim – to determine the benefit of routine oxygen administration to terminally ill patients who are near death • Design – repeated measures, double – blinded, randomized cross-over, using the patient as his/her own control • Approval obtained from the Wayne State University IRB • Funding obtained from the Blue Cross Blue Shield of MI foundation

9. The benefit of routine oxygen administration for terminally ill patients who are near death • Sample – patients who are near death and at risk of experiencing dyspnea • n = 32 (effect size 0.25, significance 0.05, power 0.80, correlation coefficient between measures 0.30) • Near death – Palliative Performance Scale ≤ 30 • At risk for dyspnea but in no distress • COPD • Heart failure • Lung Cancer • Pneumonia

10. The benefit of routine oxygen administration for terminally ill patients who are near death • Protocol • Obtain patient or family consent • Apply capnoline to patient’s nose and Y-connector to oxygen and air flow meters • Cover flow meters with bath towel • Randomly alternate oxygen, air, or no flow every 10 minutes until 6 encounters/patient • Data collector steps out of room for flow change

11. The benefit of routine oxygen administration for terminally ill patients who are near death Measures Respiratory Distress Observation Scale (RDOS) score – range 0 – 16, high score signifies distress Measured at baseline and 10 minutes after gas or flow change Baseline RDOS ≤4 RDOS >4 during trial signified distress SpO2 Et-CO2

12. Trial Profile Palliative Care consults n= 521 Eligible patients n = 114 No consent, n = 73 Enrolled, n = 32 Declined, n = 9 Family unavailable for in-person consent, n = 64

13. Results • 27 (84%) had oxygen flowing at baseline • Reason for oxygen cannot be answered • 29/32 (91%) patients experienced no distress during the protocol • 3 patients were restored to baseline oxygen • 1 patient died during the protocol

14. Results • Average RDOS at baseline = 1.47 (0-4) • No differences in patient comfort were seen across gas and flow conditions (F = 0.55, p = 0.74, n = 29)

15. Results • Average SpO2 at baseline = 93.6 (69-100) • No statistically significant change over time (F = 1.97, p = 0.09, n = 26) • Some patients (n=12) received morphine in the 8 hours before the protocol (avg. 7.3 mg) • No relationship to baseline RDOS (Χ2 = 0.78, p = 0.94)

16. Limitations • Missing SpO2 data for six patients • Hypothermia and/or hypotension • Incomplete blinding during “no flow” arm of protocol

17. Conclusions • Declining oxygen saturation is naturally occurring and expected • Declining oxygen saturation may predict but does not signify respiratory distress • The routine application of oxygen to most patients who are near death is not supported • An n of 1 trial of oxygen is appropriate in the face of respiratory distress

18. Acknowledgements • Hossein Yarandi, PhD • Statistician, WSU CON • Emily Dove-Medows, RN, MSN • Research Nurse, DRH • Judy Wheeler, RN, MSN, GNP • Palliative Care NP, DRH • Julie Walch, RN, MSN, FNP • Palliative Care NP, DRH • Denise Grabowski, RN, BSN • Angela Hospice