The Aide Alone at 2 A.M.
It is 2 a.m. in a rural home hospice. The aide, Marcus, is the only caregiver present; the family went to a hotel for the night. His patient, Mrs. Okafor, 84, has end-stage COPD and a signed Do Not Resuscitate order posted on the refrigerator. Marcus finds her unresponsive, breathing about 6 times a minute with long pauses, skin mottled from the knees down, and a faint pulse he can barely feel. Her mouth is dry and crusted, and she has a small pressure injury on her sacrum. The agency's on-call nurse is 45 minutes away. Marcus has a cell phone but spotty service.
1. What are Marcus's immediate priorities in the first five minutes?
Read the worked answer
1. Confirm and stay. Check for response and breathing. Given the DNR, he does not start CPR. He stays with her and calls the on-call nurse.
2. Comfort measures within aide scope: gentle mouth care with moist swabs, reposition slightly if it eases breathing, keep her warm and the room calm, talk softly.
3. Call for help: on-call nurse first; if no service, move to a spot with signal or use the home phone. If the nurse cannot be reached, follow the agency's emergency plan (backup number, 911 only for an emergency not covered by the DNR - and here the DNR governs).
4. Do not leave her alone unless absolutely necessary to get a signal; keep the phone on speaker.
Why: The DNR is the controlling order. The aide's role is comfort, presence, and rapid notification, not rescue. Mouth care and positioning are squarely within scope and address her actual distress.
2. Should Marcus call 911? Explain the reasoning and what he would say if he did.
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No - not for expected dying. Six breaths a minute with pauses, mottling, and unresponsiveness are expected signs of active dying in end-stage COPD. The DNR means no resuscitation. Calling 911 would risk unwanted CPR and a chaotic death in the home.
Exception: If there were a new emergency unrelated to the dying process - a fire, a fall with major bleeding, an unsafe situation - he would call. That is not this.
If he did call for a genuine emergency, he would say: "Home hospice patient, DNR on file, expected end-of-life changes, I need [specific emergency]." He would not say "she's dying, come quick."
Escalate instead: keep trying the on-call nurse and the agency's after-hours line. Document times of each attempt.
3. The family is unreachable and the nurse is 45 minutes out. What should Marcus document and how should he prepare the home?
Read the worked answer
Document (objective, timed):
- 2:00 - found unresponsive, ~6 breaths/min with pauses, mottling to knees, faint pulse, dry mouth, sacral wound intact.
- 2:02 - called on-call nurse, no answer; left message.
- 2:05 - mouth care given; repositioned; spoke softly.
- 2:10 - called agency after-hours line; nurse en route, ETA 45 min.
- Attempts to reach family, times and numbers.
Prepare the home:
- Keep her clean, warm, and comfortable; continue mouth care.
- Gather her DNR paperwork and place it where responders can see it.
- Turn on a light at the door for the nurse; note the address and gate code.
- Do not move her or start cleaning up the room in ways that would disturb her.
Why: Clear, timed documentation protects the patient, the aide, and the agency, and gives the arriving nurse an accurate picture. Preparing the environment supports a calm death and a smooth handoff.