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The guidelines for palliative care in covid-19, which the National Board of Health and Welfare issued in April, were clear from the outset that oxygen should be used in the event of severe oxygen deficiency:
“Try oxygen therapy, especially with oxygenation below 90 percent.”
But as the news from Sörmland described, they changed. In the current version, which was published in May, the wording is more vague:
“Try oxygen if necessary, but remove oxygen if symptoms have not relieved within an hour.”
The new version also states that “it is generally not necessary to measure end-of-life saturation (oxygenation in the blood, red note),” and the reason for this is claimed to be that there is a low connection between perceived and actual oxygen at that stage.
Before death, you can experience a lack of oxygen (difficulty breathing) even if you don’t have it. In these cases, oxygen does not help.
During the pandemic, however Doctors around the world have been alerted to another phenomenon in COVID-19 patients: on the contrary, they can have severe hypoxia without showing symptoms such as shortness of breath. It has been called “silent hypoxia.”
In Norway, nursing homes have been equipped with oxygen. The Norwegian Health Directorate described to DN in May that the issue had become relevant as many older people had suffered from silent hypoxia.
According to the British health authority NHS, oxygenation should be measured during end-of-life care in a hospital.
Photo: Jenny Ingemarsson
The World Health Organization (WHO) lists oxygen among the drugs that should be available. When asked by DN whether oxygen should be used in the palliative care of elderly covid patients, Andrei Muchnik from the WHO press service responds:
“Oxygen is part of the basic palliative care package that is part of our medical guidelines.”
Of the more than 5,800 in Sweden who died from COVID-19, just over 2,600 have lived in special housing, according to figures from September 21. Most have died at the residence.
The new guidelines in Sweden it occurred more quickly and with a less extensive round of inquiries than usual. DN has reviewed the eleven responses from agencies that only had a little over a day to respond, in early April, when the spread of the infection in Sweden was high intensity.
A medically responsible nurse from Frösunda Omsorg appeals:
“It is very important that you solve this with oxygen! Although many municipalities today have difficulties obtaining skills and equipment. Otherwise, there is a risk that we will do ‘active euthanasia’ with morphine when the lack of oxygen in our patients becomes too painful. “
Several others respond, however that oxygen should not be recommended. The reason: it is not available in nursing homes, no medical reasons stated.
“Oxygen should be removed as a recommendation, as this will not be relevant for special housing and home health care,” writes the medically responsible nurse, mas, in the municipality of Gävle.
“Oxygen treatment can hardly be done on short notice,” writes a Mass in Oxelösund.
“The document must take into account the resources that will actually be available (not drug and oxygen pumps),” writes Bertil Axelsson, president of the National Council for Palliative Care.
Bengt Axelsson, an associate professor of palliative medicine, thinks it was too fast when the National Board of Health and Welfare guideline was developed.
Photo: Anneli Åsén
Relatives have testified for DN that oxygen saturation could not be measured in nursing homes. A district doctor who offered to buy and donate meters was denied the answer: “This is a residence, not a hospital.”
In a small, previously unpublished Canadian study from August, researchers concluded that perceived oxygen deficiency (shortness of breath) generally signifies an actual oxygen deficiency in covid patients.
– On the other hand, normal breathing does not have to mean good oxygenation. It is necessary to measure the oxygen saturation. We believe that meters and oxygen in nursing homes would save some lives, says Nick Daneman, one of the researchers at the University of Toronto.
Bertil Axelsson has read the preliminary results of the study, which is now being expanded.
– It is good that this investigation is being done. There is clinical experience that this is the case.
He believes that saturation meters should be available in nursing homes, and that this should be included in the guide.
– On the margins, I think some “older-older” could have taken advantage of the oxygen.
The medically responsible the nurse who warned against touching euthanasia, Helena Gustafsson, at Frösunda Omsorg AB, is now toning down her response to the query. It was about the “worst-case scenario” fears that never materialized, she says.
– It was reported from Spain where such painful situations have occurred that staff have abandoned the elderly in nursing homes. That has not been the case here. In Stockholm, they have manipulated oxygen with ASIH (advanced home care is noted), and soon it was possible to send the elderly to geriatrics. All people with covid-19 do not need oxygen. I have not received any reports that someone did not have anything that they really needed.
Employees of ASIH, a mobile team that can provide oxygen, describe to DN, however, that the resource was barely used for nursing homes during the pandemic.
Ulrica Carlsson, more in the municipality of Gävle:
– There is no oxygen in our homes. We don’t have oxygen in the wall. If a doctor thinks someone should be given oxygen, doctors prescribe it separately. It is not a general recipe, but an individual one.
The head of the department of the National Board of Health and Social Welfare, Thomas Lindén, responds that the recommendation was modified “after comments on the wording.” When asked if resources were considered rather than knowledge of the best possible care, he responds:
– A guideline cannot be applied without its context, and if there is no oxygen in a home but the patient needs it, the patient can be sent to the hospital.
Ingmar Skoog, professor and director of the Center for Aging and Health at the University of Gothenburg, notes that oxygen is found in nursing homes in other countries.
– If the reason for changing the guidelines is that you do not have enough resources, then you must obtain those resources. There has been a huge investment in covid-19. Then there must be resources to provide the right medical care for the elderly in nursing homes, and that you can do it on the spot.
The Minister of Social Affairs, Lena Hallengren (S), recently opened a meeting with the National Board of Health and Welfare and the Swedish Health and Care Inspectorate for stricter regulations.
Read more:
Municipal politicians demand guarantee from the region for doctors on site for decisions on palliative care
New Crown Rules of the National Board of Health and Welfare Saw for Nursing Homes
Joy when curfew is lifted: “I long to hug you”
