Stern S G, Orlowski J P
Pediatric and Surgical Intensive Care Unit, Cleveland Clinic Foundation, OH 44195-5086.
Crit Care Med. 1992 Sep;20(9):1263-72. doi: 10.1097/00003246-199209000-00013.
To assess changes in the terminal care of critically ill patients before and after the institution of do-not-resuscitate (DNR) order policies, and policies on the care of the hopelessly ill.
Retrospective chart review that comprises the following groups: 82 consecutive deaths from 1981 to 1982, representing our older practice pattern of frequent utilization of terminal resuscitative efforts (group A); 37 consecutive deaths between June and December 1987, the 6-month period immediately preceding the adoption of the DNR policy (group B); and 61 consecutive deaths in calendar year 1988 after the DNR policy went into effect (group C).
Surgical ICU of a large tertiary care center.
Consecutive patients who died during the study periods before and after the implementation of a DNR policy.
The implementation of hospital-wide policies on DNR orders and care of the hopelessly ill patient.
There were no significant differences between the three groups for age, Acute Physiology and Chronic Health Evaluation II scores, Mortality Risk Ratio scores, or lengths of ICU stay. There was a significant (p less than .0001) decrease in the frequency of terminal resuscitative efforts, as evidenced by a decrease from 52% in group A to 3% in group C. The preterminal identification and acceptance of imminent death increased over the study period with an increase (p less than .0001) in the application of DNR orders from 46% in group A to 98% in group C. The ability to withdraw support increased (p less than .0001) from 23% in group A to 73% in group C.
We believe that our data exemplify how our ICU has been able to identify hopelessly ill patients, and how it has implemented specific levels of care that take into account not only medical prognostication, but also the wishes of the patients and their families, while maintaining an atmosphere of comfort and dignity. We demonstrated an important change in the philosophy of care for hopelessly ill patients, which was associated with the institution of DNR policies.
评估实施“不要复苏”（DNR）医嘱政策及绝症患者护理政策前后危重症患者临终护理的变化。
回顾性病历审查，包括以下几组：1981年至1982年连续82例死亡病例，代表我们过去频繁进行临终复苏努力的实践模式（A组）；1987年6月至12月连续37例死亡病例，即DNR政策实施前紧接的6个月期间（B组）；以及DNR政策生效后的1988年日历年连续61例死亡病例（C组）。
一家大型三级护理中心的外科重症监护病房。
在实施DNR政策前后的研究期间内连续死亡的患者。
实施全院范围的DNR医嘱及绝症患者护理政策。
三组在年龄、急性生理与慢性健康状况评估II评分、死亡风险比评分或重症监护病房住院时长方面无显著差异。临终复苏努力的频率显著降低（p<0.0001），从A组的52%降至C组的3%即可证明。在研究期间，临终前对即将死亡的识别和接受程度有所提高，DNR医嘱的应用从A组的46%增加到C组的98%（p<0.0001）。撤除支持的能力从A组的23%增加到C组的73%（p<0.0001）。
我们认为，我们的数据例证了我们的重症监护病房如何能够识别绝症患者，以及如何实施特定水平的护理，这种护理不仅考虑了医学预后，还考虑了患者及其家属的意愿，同时保持舒适和尊严的氛围。我们展示了绝症患者护理理念的重要转变，这与DNR政策的实施相关。
