Sulmasy D P, Geller G, Faden R, Levine D M
Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD.
JAMA. 1992 Feb 5;267(5):682-6. doi: 10.1001/jama.267.5.682.
To assess (1) the effect of an ethics education intervention for medical house officers on practices surrounding "Do Not Resuscitate" (DNR) orders and (2) the association of DNR care with patient diagnosis and demographic variables.
A 1-year randomized, controlled trial.
An urban, university teaching hospital.
Eighty-eight internal medicine house officers.
House officers were arbitrarily assigned to four "firms." One firm was randomized to an extensive ethics education intervention (EI), one to a limited intervention, and two served as controls.
Charts of patients with DNR orders were reviewed for compliance with the hospital's DNR policy, which instructs that when DNR orders are written there should be (1) an attending signature, (2) documentation of reasons, (3) appropriate consent, and (4) attention to 11 concurrent care concerns (CCCs) (eg, the appropriateness of intubation, tube feedings, hospice).
Thirty-nine charts were reviewed before the intervention and 57 after. The number of CCCs per DNR order fell among patients cared for by controls (1.9 to 1.0, P less than .05) and rose among patients cared for by the EI group (0.9 to 3.8, P less than .05). Compliance with the DNR policy varied among patients with differing diagnoses. "Do Not Resuscitate" orders were signed less frequently (P = .01) for patients with the acquired immunodeficiency syndrome (AIDS) (65%) compared with patients who had other diagnoses (85%) or malignancy (91%). Similarly, appropriate consent was recorded for 59% of patients with AIDS, 83% of others, and 85% of those with malignancy (P less than .05). The number of CCCs per DNR was 0.7 for AIDS, 1.4 for others, and 2.4 for malignancy (P less than .05). In multivariate regression analysis, house officer ethics education and patient diagnosis, but not patient gender, age, race, or insurance status, were predictors of the number of CCCs per DNR.
(1) An extensive ethics education intervention can improve care for DNR patients, especially with respect to CCCs. (2) In this setting, quality of care for DNR patients varied systematically with diagnosis. These results have implications for the design and implementation of ethics education programs.
评估（1）针对住院医师的伦理教育干预对围绕“不要复苏”（DNR）医嘱的实践的影响，以及（2）DNR护理与患者诊断和人口统计学变量之间的关联。
一项为期1年的随机对照试验。
一家城市大学教学医院。
88名内科住院医师。
住院医师被随机分配到四个“医疗团队”。一个医疗团队被随机分配接受广泛的伦理教育干预（EI），一个接受有限干预，另外两个作为对照组。
对有DNR医嘱的患者病历进行审查，以评估是否符合医院的DNR政策，该政策规定开具DNR医嘱时应具备（1）主治医生签字，（2）理由记录，（3）适当的同意，以及（4）关注11项并发护理问题（CCCs）（例如，插管、管饲、临终关怀的适宜性）。
干预前审查了39份病历，干预后审查了57份。对照组护理的患者中每份DNR医嘱的CCCs数量下降（从1.9降至1.0，P<0.05），而EI组护理的患者中该数量增加（从0.9增至3.8，P<0.05）。不同诊断的患者对DNR政策的遵守情况各不相同。获得性免疫缺陷综合征（AIDS）患者的“不要复苏”医嘱签字频率较低（P = 0.01）（65%），而其他诊断患者（85%）或恶性肿瘤患者（91%）的签字频率较高。同样，AIDS患者中有59%记录了适当的同意，其他患者为83%，恶性肿瘤患者为85%（P<0.05）。每份DNR的CCCs数量，AIDS患者为0.7，其他患者为1.4，恶性肿瘤患者为2.4（P<0.05）。在多变量回归分析中，住院医师伦理教育和患者诊断是每份DNR的CCCs数量的预测因素，而患者性别、年龄、种族或保险状况不是。
（1）广泛的伦理教育干预可以改善对DNR患者的护理，特别是在CCCs方面。（2）在这种情况下，DNR患者的护理质量因诊断不同而有系统性差异。这些结果对伦理教育项目的设计和实施具有启示意义。
