Costello John
University of Manchester, Piccadilly South, UK.
J Adv Nurs. 2002 Sep;39(5):491-9. doi: 10.1046/j.1365-2648.2002.02314.x.
This paper reports on the findings from an ethnographic study involving three wards in two hospitals in the Northwest of England and focuses on the controversial issue of Do Not Resuscitate (DNR) orders. The study aimed to explore the way in which terminal care was provided to older patients and examined the way in which DNR orders were a socially constructed part of the practices of both nurses and doctors.
An ethnographic approach was adopted that used participant observation and semi-structured interviews with nurses and doctors. A purposive sample of 28 qualified nurses and five medical staff were interviewed. The decision-making process of DNR orders became the focus of the interview questions.
The findings reveal that DNR decision-making was largely socially constructed from the interactions of hospital staff. Patients were not asked their preference and were excluded from any decision-making about Cardiopulmonary Resuscitation (CPR) or DNR orders. Two major findings emerge. First, DNR orders and the non-use of CPR could be seen as a form of medical beneficence, resulting from the often described paternalistic attitudes of hospital doctors. Second, there was a clear indication that DNR orders and the non-use of CPR for certain patients was based on improving the quality of patients' lives.
The study raises issues about the quality of care received by frail older patients whom the nurses felt would not survive a futile medical procedure. The conclusion considers the need for hospitals to formulate and implement CPR policies, particularly in the prevailing climate in which patients are encouraged to become active participants in their own health care.
本文报告了一项人种学研究的结果，该研究涉及英格兰西北部两家医院的三个病房，重点关注“不要复苏”（DNR）医嘱这一有争议的问题。该研究旨在探讨为老年患者提供临终护理的方式，并考察DNR医嘱如何成为护士和医生实践中社会建构的一部分。
采用人种学方法，运用参与观察以及对护士和医生进行半结构化访谈。对28名合格护士和5名医务人员进行了目的抽样访谈。DNR医嘱的决策过程成为访谈问题的焦点。
研究结果显示，DNR决策在很大程度上是由医院工作人员的互动进行社会建构的。未询问患者的偏好，患者被排除在关于心肺复苏（CPR）或DNR医嘱的任何决策之外。出现了两个主要发现。第一，DNR医嘱和不使用CPR可被视为一种医疗慈善形式，这源于医院医生常被描述的家长式态度。第二，有明确迹象表明，对某些患者下达DNR医嘱和不使用CPR是基于提高患者的生活质量。
该研究提出了关于体弱老年患者所接受护理质量的问题，护士认为这些患者无法在无效的医疗程序中存活。结论考虑了医院制定和实施CPR政策的必要性，尤其是在鼓励患者积极参与自身医疗护理的当前环境下。
