Wilson W C, Smedira N G, Fink C, McDowell J A, Luce J M
Department of Anesthesia, University of California, San Francisco.
JAMA. 1992 Feb 19;267(7):949-53.
To determine why and how sedatives and analgesics are ordered and administered during the withholding and withdrawal of life support from critically ill patients.
Prospective case series.
Medical-surgical intensive care units at a county hospital and a university hospital.
Consecutive 1-year sample of 22 patients from whom life support was withheld or withdrawn in one intensive care unit at a county hospital and a random sample of 22 similar patients in the intensive care unit in the university hospital over the same period.
Physicians and nurses were interviewed to determine their reasons for ordering and administering drugs, and medical records were reviewed to document amounts of drugs ordered and administered.
Drugs were given to 75% of patients during withholding and withdrawal of life support. Patients who did not receive medication were comatose and considered incapable of benefiting from sedation and analgesia. The median time until death following the initiation of the withholding or withdrawal of life support was 3.5 hours in the patients who received drugs and 1.3 hours in those patients who did not (P, not significant). Physicians ordered drugs to decrease pain in 88% of patients, to decrease anxiety in 85%, to decrease air hunger in 76%, to comfort families in 82%, and to hasten death in 39%; in no instance was hastening death the only reason cited. The amounts of benzodiazepines and opiates averaged 2.2 mg/h of diazepam and 3.3 mg/h of morphine sulfate in the 24 hours before withholding and withdrawal of life support and 9.8 mg/h and 11.2 mg/h in the 24 hours thereafter (P less than .025 and P less than .001, respectively).
Large doses of sedatives and analgesics were ordered primarily to relieve pain and suffering during the withholding and withdrawal of life support, and death was not hastened by drug administration.
确定在对重症患者停止和撤除生命支持期间，镇静剂和镇痛药的开具及使用原因和方式。
前瞻性病例系列研究。
一家县医院和一家大学医院的内科-外科重症监护病房。
在县医院的一个重症监护病房连续1年选取的22例停止或撤除生命支持的患者样本，以及同期在大学医院重症监护病房随机选取的22例类似患者。
对医生和护士进行访谈以确定他们开具和使用药物的原因，并查阅病历记录药物的开具和使用量。
在停止和撤除生命支持期间，75%的患者接受了药物治疗。未接受药物治疗的患者处于昏迷状态，被认为无法从镇静和镇痛中获益。在接受药物治疗的患者中，停止或撤除生命支持开始至死亡的中位时间为3.5小时，未接受药物治疗的患者为1.3小时（P值，无显著性差异）。医生开具药物的原因包括：减轻88%患者的疼痛、减轻85%患者的焦虑、减轻76%患者的呼吸急促感、安抚82%患者的家属以及加速39%患者的死亡；在任何情况下，加速死亡都不是唯一被提及的原因。在停止和撤除生命支持前24小时，苯二氮䓬类药物和阿片类药物的平均用量分别为地西泮2.2毫克/小时和硫酸吗啡3.3毫克/小时，之后24小时分别为9.8毫克/小时和11.2毫克/小时（P值分别小于0.025和0.001）。
在停止和撤除生命支持期间，开具大剂量镇静剂和镇痛药主要是为了减轻疼痛和痛苦，药物使用并未加速患者死亡。
