Lamberg Jennifer L, Person Carmel J, Kiely Dan K, Mitchell Susan L
Hebrew SeniorLife, Research and Training Institute, Boston, Massachusetts 02131, USA.
J Am Geriatr Soc. 2005 Aug;53(8):1396-401. doi: 10.1111/j.1532-5415.2005.53426.x.
To describe the prevalence of, timing of, and factors associated with decisions not to hospitalize nursing home residents with advanced dementia who were dying.
Retrospective cohort study.
Six hundred seventy five-bed nursing facility in Boston.
Two hundred forty residents in a teaching nursing home who died between January 2001 and December 2003 with advanced dementia.
The prevalence and timing of do-not-hospitalize (DNH) orders were determined from the medical record. Data describing demographic characteristics, health conditions, advance care planning, sentinel events, and health services usage during the last 6 months of life were examined. Factors associated with having a DNH order were identified.
At the time of death, 83.8% of subjects had a DNH order. The prevalence of DNH orders was 50.0% and 34.4%, 30 and 180 days before death, respectively. Hospital transfers were common during the last 6 months of life (24.6%). Factors independently associated with having a DNH order before death included surrogate decision-maker was not the subject's child (adjusted odds ratio (AOR)=4.39, 95% confidence interval (CI)=1.52-12.66), eating problems (AOR=4.17, 95% CI=1.52-11.47), aged 92 and older (AOR=2.78, 95% CI=1.29-5.96), and length of stay 2 years or longer (AOR=2.34, 95% CI=1.11-4.93).
For most institutionalized persons with advanced dementia, a decision to forgo hospitalization is not made until death is imminent. Thus, hospital transfers are common near the end of life. The finding that DNH orders are associated with patient and surrogate factors can help clinicians identify cases in which decisions to forgo hospitalizations may be facilitated.
描述临终时患有晚期痴呆症的疗养院居民不被收治入院的决定的发生率、时间及相关因素。
回顾性队列研究。
波士顿一家拥有675张床位的护理机构。
2001年1月至2003年12月间在一家教学型疗养院去世的240名患有晚期痴呆症的居民。
根据病历确定不收治入院（DNH）医嘱的发生率和时间。研究了描述人口统计学特征、健康状况、预先护理计划、哨兵事件以及生命最后6个月内医疗服务使用情况的数据。确定了与DNH医嘱相关的因素。
在死亡时，83.8%的受试者有DNH医嘱。DNH医嘱在死亡前30天和180天的发生率分别为50.0%和34.4%。在生命的最后6个月内，转院情况很常见（24.6%）。与死亡前有DNH医嘱独立相关的因素包括：替代决策者不是受试者的子女（调整后的优势比（AOR）=4.39，95%置信区间（CI）=1.52 - 12.66）、饮食问题（AOR=4.17，95% CI=1.52 - 11.47）、年龄在92岁及以上（AOR=2.78，95% CI=1.29 - 5.96）以及住院时间为2年或更长（AOR=2.34，95% CI=1.11 - 4.93）。
对于大多数患有晚期痴呆症的机构化患者，直到临终时才会做出放弃住院治疗的决定。因此，在生命末期转院情况很常见。DNH医嘱与患者及替代决策者因素相关这一发现有助于临床医生识别可能更容易做出放弃住院治疗决定的病例。
