Zweig Steven C, Kruse Robin L, Binder Ellen F, Szafara Kristina L, Mehr David R
Department of Family and Community Medicine, University of Missouri-Columbia School of Medicine, Columbia, Missouri 65212, USA.
J Am Geriatr Soc. 2004 Jan;52(1):51-8. doi: 10.1111/j.1532-5415.2004.52010.x.
To determine resident and facility characteristics associated with do-not-resuscitate (DNR) orders and to test the effect of DNR orders on hospitalization of acutely ill nursing home (NH) residents with lower respiratory tract infections (LRIs).
Prospective cohort.
Thirty-six NHs (almost 4,000 residents) in central and eastern Missouri in the Missouri Lower Respiratory Infection study.
NH residents with a LRI (n=1031).
Data were obtained from new Minimum Data Set evaluations, resident examination, and chart review. Associations between resident, physician, and facility characteristics and the presence of a DNR order and hospitalization within 30 days from evaluation for an LRI were analyzed.
Sixty percent of subjects had a DNR order, and 2% had a do-not-hospitalize order. Resident characteristics associated with a DNR order included older age, white race, having a surrogate decision-maker, NH residence for longer than 3 years, and more-impaired cognition. Residents with DNR orders were more likely to live in facilities with more licensed beds, a lower proportion of Medicaid recipients, and a higher prevalence of influenza vaccination. After controlling for potential confounders, residents with a DNR order before the acute illness episode were significantly less likely to be hospitalized (adjusted odds ratio=0.69, 95% confidence interval=0.49-0.97).
DNR orders independently reduce the risk of hospitalization for LRI and may function as a marker for undocumented care limitations or as a mandate to limit care (unrelated to resuscitation) in NH residents with LRI.
确定与不进行心肺复苏（DNR）医嘱相关的住院患者及机构特征，并测试DNR医嘱对患有下呼吸道感染（LRI）的急性病疗养院（NH）住院患者住院治疗的影响。
前瞻性队列研究。
密苏里州下呼吸道感染研究中位于密苏里州中部和东部的36所NH（近4000名居民）。
患有LRI的NH居民（n = 1031）。
数据来自新的最低数据集评估、住院患者检查和病历审查。分析了住院患者、医生和机构特征与DNR医嘱的存在以及自LRI评估起30天内住院情况之间的关联。
60%的受试者有DNR医嘱，2%有不进行住院治疗的医嘱。与DNR医嘱相关的住院患者特征包括年龄较大、白人种族、有替代决策者、在NH居住超过3年以及认知功能受损更严重。有DNR医嘱的居民更有可能居住在有更多许可床位、医疗补助接受者比例较低且流感疫苗接种率较高的机构。在控制潜在混杂因素后，急性病发作前有DNR医嘱的居民住院的可能性显著降低（调整后的优势比 = 0.69，95%置信区间 = 0.49 - 0.97）。
DNR医嘱可独立降低LRI患者的住院风险，并且可能作为未记录的护理限制的标志，或作为对患有LRI的NH居民限制护理（与心肺复苏无关）的指令。
