Faculty of Medicine, University of Ottawa, Ottawa, Ontario, Canada.
CJEM. 2000 Oct;2(4):246-51.
Our primary objectives were to estimate how frequently emergency medical technicians with defibrillation skills (EMT-Ds) are forced to deal with prehospital do-not-resuscitate (DNR) orders, to assess their comfort in doing so, and to describe the prehospital care provided to patients with DNR orders in a system without a prehospital DNR policy (i.e., where resuscitation is mandatory).
Using Dillman methodology, the authors developed a 13-item survey and mailed it to 382 of 764 EMT-Ds in the metropolitan Toronto area. Responses were evaluated using 5-point Likert scales, limited-option and open-ended questions. Narrative responses were categorized. Two authors independently categorized narrative responses from 20 surveys, and kappa values for agreement beyond chance were determined.
Among 382 EMT-Ds surveyed, 236 (62%) responded, of whom 221 (94%) answered the questionnaire. Overall, 126 of 219 (58%) indicated that they were called to resuscitate patients with DNR orders "sometimes," "frequently," or "all the time." In such situations, 22 of 207 (11%) stated they would honour the DNR order and 55 of 207 (27%) would honour the order but appear to provide basic resuscitation, in order to adhere to mandatory resuscitation regulations. Willingness to honour a DNR order did not vary by years of emergency medical service. EMT-Ds cited concern for the family and the patient, fear of repercussions and conflict with personal ethics as key factors contributing to this ethical dilemma. If legally allowed to honour DNR orders, 212 of 221 (96%) respondents would be comfortable with a written order and 137 of 220 (62%) with a verbal order.
Prehospital DNR orders are common, and a significant number of EMT-Ds disregard current regulations by honouring them. EMT-Ds would be more comfortable with written than verbal DNR orders. An ethical prehospital DNR policy should be developed and applied.
我们的主要目标是评估具有除颤技能的急救医疗技术员（EMT-D）处理院前不复苏（DNR）医嘱的频率，评估他们对此的舒适度，并描述在没有院前 DNR 政策的系统中（即复苏是强制性的）对 DNR 医嘱患者的院前护理。
使用 Dillman 方法，作者开发了一个包含 13 个项目的调查，并将其邮寄给大多伦多地区 764 名 EMT-D 中的 382 名。使用 5 点李克特量表、有限选择和开放式问题对回复进行评估。对叙事回复进行分类。两位作者独立对 20 份调查的叙事回复进行分类，并确定了超出机会的一致性kappa 值。
在接受调查的 382 名 EMT-D 中，有 236 名（62%）做出了回应，其中 221 名（94%）回答了问卷。总体而言，219 名中有 126 名（58%）表示他们有时、经常或一直被要求对带有 DNR 医嘱的患者进行复苏。在这种情况下，207 名中的 22 名（11%）表示他们将遵守 DNR 医嘱，55 名（27%）将遵守医嘱，但为了遵守强制性复苏法规，他们似乎会提供基本的复苏。遵守 DNR 医嘱的意愿与急救医疗服务年限无关。EMT-D 表示，担心家庭和患者、担心后果以及与个人伦理的冲突是导致这种道德困境的关键因素。如果在法律上允许遵守 DNR 医嘱，221 名中的 212 名（96%）受访者将对书面医嘱感到满意，220 名中的 137 名（62%）对口头医嘱感到满意。
院前 DNR 医嘱很常见，许多 EMT-D 无视当前规定而遵守医嘱。EMT-D 对书面 DNR 医嘱比对口头医嘱更满意。应制定和应用符合伦理的院前 DNR 政策。
