Oxygen at the End of Life

I remember taking care of a patient who took an abnormally long time to die.

The family was incredibly present at her bedside, reading to their mother from her favorite Mary Oliver book of poetry and rubbing her hands with lavender oil. I mean, it was a sweet scene every time I entered their home. 

The patient was on oxygen and had been the entire course of her illness. The oxygen concentrator incessantly buzzed in the bathroom, creating this awful noise pollution while heating the bathroom up to a balmy ninety-two degrees. 

“Why is Mom taking so long? Is there anything we are missing?” The last ten days were spent completing her unfinished business: the chaplain came to the home and gave her a final blessing, the sister flew in from Chicago, and her favorite nephew FaceTimed her from Amsterdam. The family could not think of anything else that was keeping her alive. 

Granted, sometimes it simply takes a long time to die, and there is nothing we can do about that. 

I talked to the family about taking their mom off oxygen. There is no judgment around what a family chooses to do, but as a hospice nurse, my job is to present them with options and educate them about possibilities. I said, “There is a point where oxygen can be life-prolonging. We can remove the oxygen, monitor your mom for any signs of discomfort, such as labored breathing, and medicate her if necessary. I have seen patients die shortly after or days later.”

The family decided to remove the oxygen and gathered around the bedside.

We gave her some morphine, which she had routinely. We turned off the four liters of oxygen, and she died peacefully within an hour with the family gathered at the bedside.

In my experience, and from the wisdom of the great many mentors I have had, at a certain point, oxygen prolongs life. The problem is we don't know when that point is. 

I personally never like to start oxygen on a hospice patient unless they are severely short of breath or experiencing chest pain as oxygen can be a quick fix. I prefer to manage shortness of breath with Roxanol–liquid morphine. A five mg starting dose of morphine can ease shortness of breath within an hour. Many families are afraid to initiate morphine, which is why I devoted another blog post to this topic.

I choose morphine over oxygen because the nasal cannula blowing air up one's nares can cause discomfort for folks, and the tubing can cause a pressure injury on the face or over the ears after prolonged periods. The noise of the oxygen concentrator in the home is very disruptive, and the tubing presents a tripping hazard for anyone who enters the room. 

If a patient is on oxygen, I keep them on oxygen, and this blog post discusses managing shortness of breath. If a patient is unresponsive and the family and staff are wondering why Mom is taking so long to die, I will have a conversation with them about removing oxygen. 

Legally and ethically, patients have the right to refuse any life-sustaining therapies and/or choose to withdraw any life-sustaining therapies (oxygen is life-sustaining).

And if the patient cannot make the decision because they are unresponsive, the health care representative or the family can make this decision if there is no one appointed. 

I tell families that if they will live with any regret or guilt by choosing to remove oxygen, they should not do it.

The patient will eventually die with oxygen on.

Families that choose to remove the oxygen generally know in their bones that their loved one would never want to be in this position of being completely incapacitated and dependent on everyone for all of their care, and the choice feels clear.

When patients are on huge amounts of oxygen, such as thirty liters, I have slowly lowered the oxygen over the course of the day while giving the patient morphine and Ativan to keep them comfortable.

The goal is always comfort.

When a patient is on four liters or less, you can slowly lower it or turn it off right away, although I prefer to medicate with some Roxanol and wait an hour and then remove the oxygen.

Patients have died within twenty seconds of removing the oxygen or days later. 

In my experience, most patients die within a few hours to 24 hours.

For most families, removing oxygen can feel like a difficult decision, and if this is the case I recommend keeping the oxygen on so there is no guilt or regret afterward.

But if the family is clear about their loved one’s wishes and desires, the choice to remove oxygen feels right. You will definitely want to be in conversation with your hospice team and invite the nurse over to discuss and possibly be present for this as they can advise along the way. The goal is for the patient to be as comfortable as possible at the end of their life. Removing oxygen could potentially cause labored breathing, and the hospice team can advise on how to prevent this with medications. 

Blessings. 

Are you taking care of a hospice patient?

My end-of-life guidebook for patients and their caregivers offers information about how to care for the dying.