Iserson K V
Center for Clinical Medical Ethics, University of Chicago.
J Med Ethics. 1991 Mar;17(1):19-24. doi: 10.1136/jme.17.1.19.
Approximately 400,000 people die outside US hospitals or chronic care facilities each year. While there has been some recent movement towards initiating procedures for prehospital Do Not Resuscitate (DNR) orders, the most common situation in the US is that emergency medical systems (EMS) personnel are not authorized to pronounce patients dead, but are required to attempt resuscitation with all of the modalities at their disposal in virtually all patients. It is unfair and probably unrealistic for EMS personnel to have to make a determination of the validity of a non-standard prehospital DNR order (for example, a living will or a durable power of attorney for health care). Existing prehospital DNR protocols range from being very restrictive in the scope of patients allowed to participate and in their implementation, to those that are more liberal. Potential benefits of prehospital DNR orders include freeing up vital personnel and material for use by those who would more fully benefit, and alleviating the enormous emotional strain on patients, families, EMS personnel, and hospital medical staffs involved in unwanted resuscitations that only prolong the dying process. Given this, prehospital DNR orders present several legal and moral problems. These include proper patient identification, the nature of the document itself, precautions incorporated into a DNR system to prevent misuse, potential liability for EMS and hospital personnel, and potential errors in implementation. Functioning prehospital DNR systems need to include: 1) specific legislation detailing the circumstances in which such a document could be used, the wording of such a document, and protection from liability for those implementing the document's directives; 2) having the currently valid document immediately available to the EMS personnel or base station doctors; and 3) acceptable means of identifying the patient. Relatively few US jurisdictions as yet have a prehospital DNR order system, although it is an idea whose time is overdue. Society's imperative to use available technology has pushed us into a situation where a technique to save those with a potential to continue a meaningful and wanted existence is being used indiscriminately to prolong the agony of death.
每年约有40万人在美国医院或长期护理机构之外死亡。尽管最近在启动院外“不要复苏”（DNR）指令程序方面有了一些进展，但美国最常见的情况是，紧急医疗系统（EMS）人员无权宣布患者死亡，而是几乎要对所有患者动用他们所能使用的一切手段进行复苏尝试。让EMS人员去判定一份非标准的院外DNR指令（例如，生前预嘱或医疗保健持久授权书）是否有效，既不公平，也可能不现实。现有的院外DNR方案在允许参与的患者范围及其实施方面，有的非常严格，有的则较为宽松。院外DNR指令的潜在好处包括：为那些能从救助中获得更大益处的人腾出重要的人员和物资，并减轻患者、家属、EMS人员以及参与不必要复苏（只会延长死亡过程）的医院医护人员所承受的巨大情感压力。鉴于此，院外DNR指令带来了一些法律和道德问题。这些问题包括正确识别患者、文件本身的性质、DNR系统中为防止滥用而采取的预防措施、EMS和医院人员的潜在责任以及实施过程中可能出现的错误。有效的院外DNR系统需要包括：1）详细规定此类文件使用情形、文件措辞以及对执行文件指令者的责任豁免的具体立法；2）让EMS人员或基地医生能立即获取当前有效的文件；3）可接受的患者识别方式。尽管这是一个早就该实施的想法，但美国目前只有相对较少的司法管辖区拥有院外DNR指令系统。社会对利用现有技术的迫切需求把我们推到了这样一种境地：一种本应用于拯救那些有可能继续有意义且被渴望的生命的技术，却被不加区分地用于延长死亡的痛苦。
