Folole Muliaga

Adult domiciliary oxygen therapy. Position statement of the Thoracic Society of Australia and New Zealand (2005)

Domiciliary oxygen therapy is an effective but potentially expensive and inconvenient intervention. It should be prescribed only for patients in whom there is evidence of benefit, such as those whose disability relates to a chronic reduced arterial oxygen concentration (chronic hypoxaemia).

A small cylinder of oxygen for emergency use by the patient with severe asthma who is prone to sudden life-threatening episodes is recommended.

Patients having intermittent oxygen therapy should also undergo periodic reassessment, particularly to determine whether they qualify for continuous oxygen therapy. (This is therapy for a minimum of 15 hours per day).

(Can be read in full at http://www.mja.com.au/public/issues/182_12_200605/mcd10865_fm.html )

The most common cause of chronic hypoxaemia in Australia and New Zealand is chronic obstructive pulmonary disease (COPD). In hypoxaemic COPD, domiciliary oxygen is the only therapy (apart from smoking cessation) that reduces mortality. There is also evidence that it alleviates right heart failure caused by cor pulmonale, enhances neuropsychological function, and improves exercise performance and capacity to undertake the activities of daily living. The recommendation is generally that the oxygen be used for as many hours out of 24 as possible, within reason. The benefit of daytime oxygen use, which may restrict mobility, must be weighed against the benefit of exercise, which can improve quality of life.


Of all the delivery systems used by oxygen-dependent patients, oxygen concentrators are the most common. An oxygen concentrator is an electrical medical device which extracts oxygen from the surrounding air. This air is then delivered to the patient using a plastic tube connected to a nasal cannula. Concentrators are usually the most economical method of providing oxygen therapy at home, but they only supplement the concentration of O2 to the patient.

Back-up methods are necessary in case of a power failure and most home care providors will offer 24-hour emergency service and be available through an answering service. This allows the patient to have a contact in the event of an emergency such as a power failure or equipment malfunction.

Smoking is the primary risk factor for COPD. Approximately 80 to 90 percent of COPD deaths are caused by smoking. Female smokers are nearly 13 times as likely to die from COPD as women who have never smoked.The quality of life for a person suffering from COPD diminishes as the disease progresses. At the onset, there is minimal shortness of breath. People with COPD may require supplemental oxygen but eventually they may have to rely on mechanical respiratory assistance (ie a ventilator in a hospital).

This case is intriguing as it would appear that Mrs Muliaga was on continuous or intermittent O2 therapy and was using it to improve her standard of life and also therapeutically to prevent her developing right sided cardiac failure. This does not mean that she could not survive without her O2 for reasonable periods of time.

Several questions have to be asked:-

Where was her emergency back-up O2 supply? Had it been used and then neglected to be refilled? Or, as she did not have severe asthma, it may have been decided that she was at no risk from O2 supply failure and therefore did not need one.

If her disease was so severe that she could not live without the small increase in arterial oxygenation supplied by her O2 concentrator, should she not have been in a hospital rather than at home? Had she been compliant with her therapy and attendance at the hospital?

Had she recently acquired a respiratory infection, deteriorated but not been taken to her doctor for additional treatment or hospitalisation?

Why had the family not contacted the DHB? They would have been supplied with advice about what to do if the event of failure of the device and surely the one thing that would have been emphasizd is to contact the hospital.

While I have sympathy for the family of Mrs Muliaga, I have no doubt that the discontinuation of the electricity, in normal circumstances, should not have caused her death. They seem to be a very unsophisticated family, bewildered by the array of modern conveniances and medical therapeutic methods; but they would most probably have been given by the hospital all the assistance and education needed about her ilness and it's management. Non-compliance or poor motivation to seek help are the most likely culprits in the deterioration in her condition, maybe to the extent that she should have been hospitalised prior to the events, and that the loss of her O2 concentrator created panic, an increse in O2 requirements (beyond that which could have been supplied by her machine), hypoxaemia, decreased mental alertness and followed by a cardiac arrest.

Three occurences since have incensed me. The first is Clark trying to get political brownie points by visiting the family and the second is the politicisation of her death by the 'Professor' of General Practice at Otago University. And lastly is the $10 000 given to the family by Mercury Energy. Pay for the funeral if you want to be nice, but a monetary bribe is unacceptable.

Update:

The family who could not pay their electricity bill are now going to spend about $100 000 on a funeral!

Sheenan has come out swinging at the police investigation about how it is culturally inappropriate to interview the family in English - but at the funeral they are going to have hymns in Samoan and English?

Clarke has said that there has been no 'Human Decency' shown by the electricity contractor - she should know! Mmmmm...