Moselli N M, Debernardi F, Piovano F
Unit of Anaesthesiology, Intensive Care and Pain Therapy, Institute for Cancer Research and Treatment (IRCC), Candiolo (Torino), Italy.
Acta Anaesthesiol Scand. 2006 Nov;50(10):1177-86. doi: 10.1111/j.1399-6576.2006.01150.x.
As evidence exist that severe neurological damage or prolonged death after inappropriate CPR could occur, restraints and indications for CPR were perceived as necessary. The objective of this review is to examine policies and attitudes towards end-of-life decisions in Europe and North America and to outline differences and similarities.
A bibliographic database search from 1990 to 2006 was performed using the following terms: do-not-resuscitate orders, end-of-life decisions, withholding/withdrawal of life-sustaining treatments, medical futility and advanced directives. Eighty-eight articles, out of 305 examined, were analyzed and their data systematically reported and compared where possible. They consisted of studies, questionnaires and surveys answering the following questions: percentage of deaths of critical patients preceded by do-not-resuscitate orders, factors affecting the decision for do-not-resuscitate orders, people involved in this decision (patient, surrogates and medical staff) and how it was performed.
There is an evident gap between the North American use of standard and formal procedures compared with Europe. Second, they diverge in the role acknowledged to surrogates in the decisional process, as in Europe, restraints and reserves to accept surrogates as decision makers seem still strong and a paternalistic approach at the end-of-life is still present.
Incidentally, despite the predictable differences between Europe and North America, concerns do exist about the actual extent of autonomy wished by patients and surrogates. It is important to highlight these findings, as the paternalistic attitude, too often negatively depicted, could be, according to the best medical practice, justified and more welcomed in some instances.
由于有证据表明，不适当的心肺复苏术可能导致严重的神经损伤或延长死亡时间，因此人们认为有必要对心肺复苏术进行限制并明确其适用指征。本综述的目的是研究欧洲和北美的临终决策政策及态度，并概述其中的异同。
使用以下术语对1990年至2006年的文献数据库进行检索：不要复苏医嘱、临终决策、维持生命治疗的 withhold/撤 除、医疗无效和预先指示。在审查的305篇文章中，对88篇进行了分析，并尽可能系统地报告和比较了它们的数据。这些文章包括研究、问卷和调查，回答了以下问题：下达不要复苏医嘱的重症患者死亡百分比、影响下达不要复苏医嘱决策的因素、参与该决策的人员（患者、代理人和医务人员）以及决策的执行方式。
与欧洲相比，北美在标准和正式程序的使用上存在明显差距。其次，它们在代理人在决策过程中所扮演的角色上存在分歧，在欧洲，对接受代理人作为决策者的限制和保留似乎仍然很强，临终时的家长式做法仍然存在。
顺便提一下，尽管欧洲和北美之间存在可预见的差异，但对于患者和代理人所期望的实际自主权程度仍存在担忧。强调这些发现很重要，因为家长式态度虽然常常被负面描述，但根据最佳医疗实践，在某些情况下可能是合理的，并且更受欢迎。
