口头院前 DNR 政策的潜在影响。

Robert Wood Johnson Clinical Scholars Program, University of California, Los Angeles, California, USA.

Prehosp Emerg Care. 2009 Apr-Jun;13(2):169-72. doi: 10.1080/10903120802471923.

BACKGROUND

Forgoing resuscitation in prehospital cardiac arrest has previously required a written prehospital do-not-resuscitate (DNR) order. Some emergency medical services (EMS) agencies, including Los Angeles County (LAC), have implemented policies allowing surrogate decision makers to verbally request to forgo resuscitation. The impact of a verbal DNR policy is unclear, given the absence of information about how often cardiac arrest occurs at home, or in the presence of a family member.

OBJECTIVE

To determine the prevalence of written DNR forms, rate of resuscitation, location of cardiac arrest, and availability of a family member in nontraumatic cardiac arrest prior to implementation of the new policy in LAC.

METHODS

All prehospital run sheets for nontraumatic cardiac arrest in LAC were reviewed for the first seven days of each month (August 2006-January 2007) for DNR status, location of cardiac arrest, presence of family members, and whether resuscitation was attempted.

RESULTS

Of the 897 cardiac arrests, 492 occurred at home, 111 in a public place, and 93 in a nursing home (location was unknown for 201). Fifty-five patients (6%) had a written DNR order, although it was not always available. Of these 55 patients, ten were resuscitated, the majority of the time because the family could not produce the paperwork. A family member was listed as present 29% of the time (261 of 897 cases). A medical history was obtained in an additional 465 cases (52%), indicating that someone familiar with the patient's medical history was present more than half the time, even when a family member was not mentioned.

CONCLUSIONS

A written DNR order is uncommonly used in the prehospital setting as a reason to forgo resuscitation in LAC. Even when family members state that the patient has a DNR order, patients are often resuscitated. A majority of cardiac arrests occurs at the patient's home, and in many cases in the presence of family members, some of whom may be able to express a patient's preferences regarding end-of-life care.

背景

在院外心脏骤停中放弃心肺复苏术之前，需要有一份院外的不复苏（DNR）书面医嘱。一些急救医疗服务（EMS）机构，包括洛杉矶县（LAC），已经实施了允许代理人通过口头请求来放弃复苏的政策。鉴于在家中或有家庭成员在场的情况下，心脏骤停的发生频率或有关信息的缺乏，口头 DNR 政策的影响尚不清楚。

目的

确定在 LAC 实施新政策之前，非创伤性心脏骤停中书面 DNR 表格的流行率、复苏率、心脏骤停的位置以及家属的可用性。

方法

审查 LAC 中每个月的前七天（2006 年 8 月至 2007 年 1 月）的所有院外运行表，以确定 DNR 状态、心脏骤停的位置、家属的存在以及是否尝试复苏。

结果

在 897 例心脏骤停中，有 492 例发生在家中，111 例发生在公共场所，93 例发生在疗养院（201 例位置未知）。尽管并非总是可获得，但有 55 例患者（6%）有书面 DNR 医嘱。其中 10 例接受了复苏治疗，大多数情况下是因为家属无法提供书面文件。有家属在场的情况占 29%（897 例中有 261 例）。另外，有 465 例（52%）获取了病史，这表明即使没有提到家属，熟悉患者病史的人也有一半以上的时间在场。