The Nursing Home Resident with Breathlessness
You are called to a nursing home to a 79-year-old woman with a history of COPD and heart failure. Staff report she has become increasingly breathless over 6 hours and is now too breathless to speak in full sentences. She is sitting upright, tripoding, using accessory muscles, with a respiratory rate of 32, SpO2 84% on room air, pulse 112 and irregular, blood pressure 138/84. She has bilateral basal crackles and pitting oedema to mid-shin. She is alert but frightened. Her medication chart lists furosemide, a beta-blocker, and a long-acting bronchodilator; staff say she 'refused her inhalers today'. There is a 'Do Not Attempt Resuscitation' order in her file, signed and dated, and her daughter is on the phone demanding she be 'put on oxygen immediately and taken to hospital'.
1. Differentiate the likely contributors to her breathlessness and explain how that differentiation changes your treatment priorities.
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There are at least three plausible contributors and they pull treatment in different directions:
- COPD exacerbation: she has refused her long-acting bronchodilator today, and COPD patients can present with breathlessness, wheeze and hypoxia. Bronchodilators and controlled oxygen are relevant.
- Acute decompensated heart failure: bilateral basal crackles, pitting oedema, orthopnoea (sitting upright/tripoding) and an irregular pulse suggest fluid overload and possibly atrial fibrillation. This supports cautious fluid management and positioning, and makes indiscriminate high-flow oxygen and large fluid boluses potentially harmful.
- Arrhythmia: the irregular tachycardia may be driving or worsening both.
The key judgement is that oxygen is a drug with a target range, not 'more is better'. In a COPD patient with possible CO2 retention, you titrate oxygen to a target saturation (commonly 88–92% in known COPD at risk of hypercapnia, per local protocol) rather than blasting high-flow oxygen. You prioritise positioning, controlled oxygen titration, monitoring and reassessment, and you do not assume a single diagnosis. The daughter's demand for 'oxygen immediately' is partly right (she needs oxygen) but the dose and target matter.
2. How do you handle the DNAR order and the daughter's instructions, and what is your reasoning?
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- A valid, signed and dated DNAR order applies to CPR in the event of cardiac arrest. It does not mean 'do not treat'. She is currently alive and breathless, and she is entitled to full active treatment for her reversible problems: oxygen titration, positioning, bronchodilators, monitoring, and transport if appropriate.
- The daughter is not the decision-maker for a patient who is alert. The patient's own wishes take precedence. Where possible, establish the patient's wishes directly, gently and at her pace, given she is breathless.
- Explain to the daughter, calmly and without confrontation, what the DNAR means and does not mean, and that you are actively treating her mother. Do not disclose clinical details she is not entitled to without the patient's agreement; keep the conversation focused on the care being given.
- Document the DNAR, the patient's expressed wishes, the daughter's concerns and your actions. If there is doubt about the validity of the DNAR or the patient's capacity, treat and escalate; do not let uncertainty become a reason to withhold reversible care.
3. She deteriorates on scene: respiratory rate falls to 10, she becomes drowsy, and SpO2 rises to 99% on the oxygen you applied. What is your interpretation and what do you do?
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This is a worrying pattern: a falling respiratory rate with drowsiness and a 'good' saturation in a COPD patient suggests hypoventilation and possible CO2 retention - the saturation can look reassuring while ventilation is failing. A rising SpO2 with a falling respiratory rate and decreasing consciousness is not improvement.
Actions:
- Reduce the inspired oxygen to bring saturation back toward the target range for this patient, rather than continuing high-flow oxygen.
- Support ventilation: ensure a patent airway, consider airway adjuncts and assisted ventilation per your scope and protocol, and monitor closely.
- Reassess level of consciousness, respiratory rate and effort frequently, and prepare for possible deterioration.
- Reconsider the DNAR: it applies to cardiac arrest, not to assisted ventilation or other active treatment. Continue active management.
- Pre-alert and transport promptly, communicating the oxygen history, the target range, and the change in consciousness.
The judgement being tested is that you treat the patient, not the number on the oximeter.