The aim of this assignment is to analyse a critical incident in the care of a patient with a severe of life threatening illness, in this case a patient with COPD. I will critically analyse the ethical, legal and professional implications arising from the incident and apply and analyse appropriate research findings. For the purpose of this essay a pseudonym will be used to protect the patients confidentiality, according to The Nursing and Midwifery Councils Code of Professional Conduct (NMC 2002). For the purpose of this essay the patient will be referred to as Joe.
This particular critical incident was chosen because I admitted Joe to the ward and he was placed on my nursing team. I was able to build up a relationship with him and became involved with his care until the time he was transferred to another ward. A critical incident can be described as dissecting an event in which one aspect of the event is explored, the moment, which determined its outcome and prompted conclusions (Hogstonet al 2002). Hogston et al (2002) also believe critical incident analyses ensure maximum learning is sought and the nursing activity subject to further formal analysis.
Joe was admitted to the accident and emergency department following a severe bout breathlessness. He was brought in via ambulance and given oxygen. Basic observations were taken, such as, blood pressure, pulse and oxygen saturations. Joe’s peak flow was taken. Eventually diagnosed as having an acute on chronic episode of COPD (Chronic obstructive pulmonary disease). In COPD, the airways have become obstructed, and the alveoli damaged. Causes of the blockage include an increased amount of mucus in the airways and narrowing of the passages as a result of the airway walls becoming thickened.
Emphysema is the term for the damage to the lung tissue in COPD that affects the ability of the alveoli to transfer air into the body. When observing Joe’s oxygen saturation and respirations I also supervised him doing a peak flow. I noticed that he still appeared short of breath and could only manage two attempts of performing the peak flow; at the time I felt this was adequate for his measurements as it was making him appear more dyspnoeic, anxious and distressed. However Hogston et al (2002) state three sequential readings should be made.
Alexander et al (2000) support this by stating the best of three attempts of a peak flow should be documented. Peak flows are an important assessment to make (Alexander et al 2000). However they were not appropriate at this time as Joe was already suffering from severe breathlessness, and it was obvious his respirations were very low. I felt that instead of asking Joe to perform peak flows the doctor should have assessed his airway, breathing and circulation; this would have allowed an early and quick assessment. This would have been more beneficial, and was less demanding for Joe.
The European Resuscitation Council (1998) state the ‘look, listen and feel’ approach can be used to evaluate the effectiveness of breathing, the work of breathing and the adequacy of ventilation. Evidence has shown a timely assessment and early recognition of actual or potential problems is essential to ensure the optimal outcome for the patient (Cole 2004). Early recognition of potential and actual deterioration of Joe is essential, and should be accompanied by an appropriate response of an intervention (Longmore et al 2000). Airway assessment is a way of determining potency of the upper airways.
Observing for breathing determines adequate ventilation (Ahern et al 2002). Goldhill et al (1999) states the patient’s respiratory rate is accepted as being the most basic observation in detecting any patient’s deterioration. Joe was commenced on oxygen therapy; which relieved the symptoms of breathlessness. Administrating oxygen reduces or corrects hypoxia by compensating for the reduced minute volume (Bennett 2003). Bennett et al (2003) state that oxygen can be delivered in a number of ways, it was important to ensure the method chosen was the appropriate device.
Joe had a basic o2 mask and it was decided that Joe would benefit from a venturi mask providing 28% of oxygen. I was asked to change Joe’s o2 mask to a venturi mask giving 28% oxygen to begin with. This was an advantage as venturi masks are useful when it is necessary for the patient to be administered accurate concentrations of oxygen for example in COPD (Bennett 2003). Dougherty et al (2004) support this by stating that venturi-masks are the safest option for patients when a known amount of oxygen is required or when efficient elimination of carbon dioxide is needed, for example in patients with COPD.
Barsby et al (2000) state the maximum oxygen concentration a COPD patient should be given is 28% via a venturi mask when being assessed and until a full medical history of the patient has been obtained. I became aware that Joe’s respirations were slowly decreasing from the morning’s baseline of 25 per minute to 13, and his oxygen saturations remained low. It was imperative to understand the importance of this due to the hypoxic drive theory. This theory applies to patients who, as a result of long standing lung damage, their alveolar ventilation is inadequate and they tolerate abnormal arterial blood gases.
The central chemoreceptors become tolerant of a high partial pressure of carbon dioxide and the kidneys compensate for the respiratory acidosis by retaining bicarbonate so the arterial pH is about normal. These patients rely on hypoxia to make them breath (hypoxic respiratory drive). If such a patient is given too much oxygen respiratory drive will be lost. They will not breathe adequately, and the partial pressure of carbon dioxide in arterial blood may rise to dangerous levels causing progressive loss of consciousness and eventually apnoea.
Once the patient stops breathing, hypoxia returns but it is not adequate to overcome the depressive effects of the high CO 2 levels, and unless the patient is artificially ventilated they may die. Because of this it is important to monitor Joe’s oxygen saturations and respiration rate. However using a machine to record Joes oxygen saturations may only be beneficial if they are above 85%, Bennett et al (2003) state that it is unethical to let a person de-saturate too less than that whilst testing the machines.
On reflection it would have perhaps been more effective to prescribe a higher percentage of oxygen at this time and then continue monitoring Joe carefully for any alterations for example lethargy or difficulty to arouse (Simmons et al 2004). I feel that this was the case because at the time it was not known if Joe suffered from hypoxia, my knowledge as a student told me that; if someone is breathless you give oxygen. However at the time the doctors were apprehensive about giving Joe to much oxygen, as they knew he suffered from COPD and were concerned about his hypoxic drive.
Ewers et al (2001) state oxygen can be delivered to treat hypoxemia, and to decrease the work of breathing. However as previously mentioned, evidence has shown doctors to be conscious of administering too much oxygen to COPD patients due to the Hypoxic Drive Theory (Simmons et al 2004). If a COPD patient who, like Joe retained carbon dioxide is prescribed a high percentage of oxygen, the hypoxic drive theory states the carbon dioxide levels will rise acutely and suppress the respiratory drive resulting in shallow breathing and eventual death (Alexander et al 2000).
However other research findings have shown that when given supplementary oxygen COPD patients who retain CO2 have a minimal decrease in their respiratory rate (Simmons et al 2004). Hoyt (1997) argues that the Hypoxic Drive Theory cannot be totally discounted in all CO2 retainers but nurses should recognise that it is unlikely that rising PaCO2 levels diminish the hypoxic drive. In Joe’s case believing this to be so it can led initially to inadequate oxygen therapy being given. Critically analysing Joe’s care, it would have been better and more important at the time for the doctor to provide him with increase oxygen to correct hypoxia.
However this was not done and Joe continued to be treated with the 35% venturi mask. Research suggests that in clinically unstable patients early intervention can reduce deterioration and prevent mortality (Buist et al 2002). Simmons et al (2004) also state that oxygen is of life saving importance in the treatment of COPD. During acute crises oxygen toxicity is not an issue, so maximal 100% oxygen should be given (Woodrow 2004). Bateman et al (1998) state that although a wide spread belief exists regarding the Hypoxic Drive Theory only 10-15% of patients with COPD may become apnoeic if given more than 28% oxygen.
However in contrast to this The British Thoracic Society COPD Guidelines (1997) state maximum concentration of oxygen therapy should be 28% via a venturi mask until the results of arterial blood gases are known. The Critical Care Outreach Service identify patients at risk of developing a critical illness and enable an intervention which is early or have the ability to transfer patients to a suitable area which meets the individuals needs (Cunningham et al 2002). Due to the role of the Outreach Teams it would have benefited the patient if they were called earlier therefore preventing the deterioration of his condition.
Evidence has shown that patients identified at risk are referred to critical care teams too late to significantly improve a patient’s outcome; therefore it is imperative management of patients on a ward is optimised by timely identification and intervention to support at risk patients (Coombs et al 2002). Cunningham et al (2002) state the patient at risk team modified early warning score (MEWS) protocol, which is a modified early warning score, enabling early recognition of acutely ill patients, should be used when nurses and doctors are concerned about a seriously ill patient.
The MEWS protocol follows the procedure of a nurse contacting a responsible doctor to inform them of any 3 or more concerns for example respiratory rate of >25 breaths per min or <10, not fully alert and orientated, oxygen saturations <90%. Joe had all of the above, therefore he was a priority and should have been provided with assistance and interventions sooner. Joe continued to deteriorate and was assessed for his level of responsiveness by asking his name. Mallet and Dougherty (2000) support this process by advising ‘to check a patients level of consciousness by eliciting a response to verbal stimuli’.
The doctor stated we should aid respiration by using the ambu-bag technique until the Outreach Team arrived on the ward. This method of ventilation was only followed for about five minutes, the patient then began breathing independently and his respirations increased to twelve per minute. I chose to observe this procedure as I had never seen any form of manual resuscitation performed on a patient until this point of my nurse training, and did not feel completely confident in performing the procedure correctly at this particular time.
Evidence has shown that interventions and treatment which is timely can help to reduce further deterioration of patient’s condition, it is felt that if the patient was provided with oxygen sooner to correct his hypoxia the deterioration which happened may have been prevented. Although the patient suffered from COPD the literature and evidence states that rarely does a patient who is provided with high concentrations of oxygen become apnoeic. Although the doctor on the ward looking after this particular area was consulted on a number of occasions throughout this incident, his approach was slightly conservative.
The only input felt to be relevant was to continue changing the patient’s venturi mask with out fully assessing the patient or his needs. Although arterial blood gases were taken within the recommended timeframe of sixty minutes, it would have being better due to the Joe’s condition to take them as soon as he arrived on the ward. However due to the ward being very busy this particular day and only three doctors allocated to it, may have played a factor as to why the approach to the patient was slow.
Only when he deteriorated further and the nurse I was working alongside was informed and approached were my concerns acted upon and appropriate treatment was sought and provided, at this point the patient was given high concentrations of oxygen via a non-rebreath mask, which would have benefited the patient sooner. The patient was also ventilated effectively when he became unresponsive. The outreach team were also called, however due to the role of the outreach teams it probably would have also being better for the patient if they were called earlier.
The outreach team felt the patient needed to be transferred to a high dependency ward where further investigations and treatment could be provided. Throughout Joe’s care there were a number of legal and ethical issues that were taken into consideration. Joe was not always given information about his treatment all the way through, and he was not told what was happening to him and why the doctors and nurses were monitoring him. There are some fundamental ethical principals that all health care professionals have to follow, and in this case I do not think they always were.
Ethical principals means recognising that patients have such basic human rights as the right to know, the right to privacy and the right to receive care and treatment. Joe had the right to know what treatment was being given to him and why, however at the doctors discretion it was decided not to tell Joe as the doctor feared it could make him panic and worsen his condition. Joe had the right to receive treatment, however due to lack of knowledge the right treatment was not given right away. Nightingale (1864) has said that above all patients should come to no harm.
However Joe did suffer as a result of poor care, based on a lack of understanding of the hypoxic drive theory. Nurses need to be aware of the physiology of respiration and be aware that patients with COPD are vulnerable and their care needs to be focused on monitoring their reaction to oxygen being given. It is arguably unethical to care for a patient without appropriate knowledge. This critical incident has been a significant learning experience, which has allowed me to be part of an unfamiliar situation, in which I had some input in the patient’s care.
Professionally I have learnt that for severely breathless patients the priority is to correct hypoxia. However, as doctors rely on nurses to keep them up to date regarding a patient’s condition and notify any alterations, maybe my concerns were not expressed confidently enough. Therefore I have learnt the need to be more assertive in my approach towards people and that at times it is necessary to challenge and question a doctor’s decision regarding care because the decision made may not always be beneficial or appropriate for the patients needs at that particular time.