Guru V, Verbeek P R, Morrison L J
University of Toronto Medical School.
CMAJ. 1999 Nov 16;161(10):1251-4.
In an environment characterized by cuts to health care, hospital closures, increasing reliance on home care and an aging population, more terminally ill patients are choosing to die at home. The authors sought to determine the care received by these patients when paramedics were summoned by a 911 call and to document whether do-not-resuscitate (DNR) requests influenced the care given.
The records of a large urban emergency medical services system were reviewed to identify consecutive patients with cardiac arrest over the 10-month period November 1996 to August 1997. Data were abstracted from paramedics' ambulance call reports according to a standardized template. The proportion of these patients described as having a terminal illness was determined, as was the proportion of terminally ill patients with a DNR request. The resuscitative efforts of paramedics were compared for patients with and without a DNR request.
Of the 1534 cardiac arrests, 144 (9.4%) involved patients described as having a terminal illness. The mean age of the patients was 72.2 (standard deviation 14.8) years. Paramedics encountered a DNR request in 90 (62.5%) of these cases. Current regulations governing paramedic practice were not followed in 34 (23.6%) of the cases. There was no difference in the likelihood that cardiopulmonary resuscitation (CPR) would be initiated between patients with and those without a DNR request (73% v. 83%; p = 0.17). In patients for whom CPR was initiated, paramedics were much more likely to withhold full advanced cardiac life support if there was a DNR request than if there was not (22% v. 68%; p < 0.001).
Paramedics are frequently called to attend terminally ill patients with cardiac arrest. Current regulations are a source of conflict between the paramedic's duty to treat and the patient's right to limit resuscitative efforts at the time of death.
在一个以医疗保健削减、医院关闭、对家庭护理的依赖增加以及人口老龄化特征的环境中，越来越多的晚期患者选择在家中死亡。作者试图确定当护理人员接到911呼叫而被召唤时这些患者所接受的护理，并记录“不要复苏”（DNR）请求是否影响所给予的护理。
回顾了一个大型城市紧急医疗服务系统的记录，以识别1996年11月至1997年8月这10个月期间连续发生心脏骤停的患者。数据根据标准化模板从护理人员的救护车呼叫报告中提取。确定这些患者中被描述为患有晚期疾病的比例，以及有DNR请求的晚期患者的比例。比较了有和没有DNR请求的患者护理人员的复苏努力。
在1534例心脏骤停病例中，144例（9.4%）涉及被描述为患有晚期疾病的患者。患者的平均年龄为72.2岁（标准差14.8）。护理人员在其中90例（62.5%）病例中遇到了DNR请求。在34例（23.6%）病例中未遵循当前关于护理人员执业的规定。有和没有DNR请求的患者开始进行心肺复苏（CPR）的可能性没有差异（73%对83%；p = 0.17）。在开始进行CPR的患者中，如果有DNR请求，护理人员比没有DNR请求时更有可能不进行全面的高级心脏生命支持（22%对68%；p < 0.001）。
护理人员经常被召唤去照料患有心脏骤停的晚期患者。当前的规定是护理人员的治疗职责与患者在死亡时限制复苏努力的权利之间冲突的一个根源。
