GASPING ON THIN AIR: SUPPLEMENTAL OXYGEN USAGE IN PALLIATIVE CARE

Abstract

SESSION TITLE: Tuesday Medical Student/Resident Case Report Posters SESSION TYPE: Med Student/Res Case Rep Postr PRESENTED ON: 10/22/2019 01:00 PM - 02:00 PM INTRODUCTION: The goals of care for patients in acute hospice are symptomatic management and comfort. Continuous oxygen usage in this population may unintentionally prolong life expectancy in some patients despite limited mobility and decreased pulmonary functionality. CASE PRESENTATION: A 58-year-old female with metastatic stage 4 invasive ductal carcinoma was admitted to the intensive care unit after a 1-year history of increased cough and dyspnea at rest. She had been treated with multiple chemotherapy agents since her initial cancer diagnosis 10 years prior including everolimus and exemestane. Her blood gases consistently yielded a pO2 in the 50s while chest radiography revealed severe peripheral and peribronchovascular patch ground-glass opacities in both lungs. Her remaining labs and echocardiogram were normal. Aggressive therapy did not alleviate her symptoms and she remained relatively motionless in bed as self-movement would cause her respiratory distress and sudden hypoxia. As her symptoms progressively worsened, the patient and the family elected to pursue comfort care with a life expectancy of a few days. Her initial comfort care regimen included lorazepam, hydroxyzine, and morphine while she remained on high flow nasal cannula for relief. During her stay, her vital signs remained stable despite a progressive functional decline at rest including worsening dyspnea, increasing delirium, and depressed mood. It was apparent that she was not at her comfort goals while her family continued to sustain continuous emotional and psychological burnout. Following request by the family, her supplemental oxygen was turned off which resulted in a rapid decline in her previously stable vital signs. The patient expired 2 hours later after spending 58 days in inpatient hospice care. DISCUSSION: Supplemental oxygen use as a benefit is a controversial topic in palliative care and hospice scenarios. One should be cautious over the use of continuous oxygen as it may paradoxically prolong the life expectancy in terminally ill patients as demonstrated in this clinical vignette. CONCLUSIONS: Previous studies in palliative oxygen use have been mixed as it can be a comfort measure or a life-sustaining intervention in patients with terminal illness. Providing supplemental oxygen may unexpectedly prolong life expectancy while causing undesired caregiver stress, undue financial burden, and psychological burnout on the family. Early discussion with family members regarding its use will set realistic expectations regarding prognosis and outcomes. We recommend conservative supplemental oxygen use in patients admitted to acute hospice with progressive functional decline. Reference #1: Fardy HJ. Oxygen therapy in palliative care. NPJ Prim Care Respir Med. 2016;26:15073. Published 2016 Jan 7. https://doi.org/10.1038/npjpcrm.2015.73 Reference #2: Truog, R D, et al. “Recommendations for End-of-Life Care in the Intensive Care Unit: a Consensus Statement by the American College [Corrected] of Critical Care Medicine.” Current Neurology and Neuroscience Reports., U.S. National Library of Medicine, Mar. 2008 Reference #3: Butterfield, Stacey. “What Not to Do in Palliative Care.” ACP Hospitalist, 15 Dec. 2015, acphospitalist.org/archives/2015/12/conference-coverage-palliative-care.htm. DISCLOSURES: No relevant relationships by Ankitha Antony, source=Web Response No relevant relationships by C, Bryan Huang, source=Web Response No relevant relationships by Lissette Jimenez, source=Web Response