Hemphill J Claude, Newman Jeffrey, Zhao Shoujun, Johnston S Claiborne
Department of Neurology, University of California, San Francisco, Calif, USA.
Stroke. 2004 May;35(5):1130-4. doi: 10.1161/01.STR.0000125858.71051.ca. Epub 2004 Mar 25.
Do-not-resuscitate (DNR) orders are commonly used after severe stroke. We hypothesized that there is significant variability in how these orders are applied after intracerebral hemorrhage and that this influences outcome.
From a database of all admissions to nonfederal hospitals in California, discharge abstracts were obtained for all patients with a primary diagnosis of intracerebral hemorrhage who were admitted through the emergency department during 1999 and 2000. Characteristics included whether DNR orders were written within the first 24 hours of hospitalization. Case-mix-adjusted hospital DNR use was calculated for each hospital by comparing the actual number of DNR cases with the number predicted from a multivariable model. Outcome (in-hospital death) was evaluated in a separate multivariable model adjusted for individual and hospital characteristics.
A total of 8233 patients were treated in 234 hospitals. The percentage of patients with DNR orders varied from 0% to 70% across hospitals. Being treated in a hospital that used DNR orders 10% more often than another hospital with a similar case mix increased a patient's odds of dying during hospitalization by 13% (P<0.001). Patients treated in the quartile of hospitals with the highest adjusted DNR use were more likely to die, and this was not just because of individual patient DNR status.
In-hospital mortality after intracerebral hemorrhage is significantly influenced by the rate at which treating hospitals use DNR orders, even after adjusting for case mix. This is not due solely to individual patient DNR status, but rather some other aspect of overall care.
“不要复苏”（DNR）医嘱在严重卒中后常用。我们推测，脑出血后这些医嘱的应用存在显著差异，且这会影响预后。
从加利福尼亚州非联邦医院所有入院患者的数据库中，获取1999年和2000年通过急诊科入院、原发性诊断为脑出血的所有患者的出院摘要。特征包括住院24小时内是否开具了DNR医嘱。通过比较DNR病例的实际数量与多变量模型预测的数量，计算每家医院经病例组合调整后的DNR使用率。在一个针对个体和医院特征进行调整的单独多变量模型中评估预后（院内死亡）。
234家医院共治疗了8233例患者。不同医院中开具DNR医嘱的患者百分比从0%到70%不等。在一家使用DNR医嘱比病例组合相似的另一家医院多10%的医院接受治疗，会使患者住院期间死亡几率增加13%（P<0.001）。在调整后DNR使用率最高的四分位医院接受治疗的患者更可能死亡，而这不仅仅是因为个体患者的DNR状态。
即使在调整病例组合后，脑出血后的院内死亡率仍受治疗医院使用DNR医嘱的比率显著影响。这并非仅由于个体患者的DNR状态，而是整体护理的其他某些方面所致。
