外科重症监护病房的不复苏医嘱调查。

Survey of do-not-resuscitate orders in surgical intensive care units.

机构信息

Department of Surgery, National Taiwan University Hospital, Taipei, Taiwan.

出版信息

J Formos Med Assoc. 2010 Mar;109(3):201-8. doi: 10.1016/S0929-6646(10)60043-5.

PMID:20434028

Abstract

BACKGROUND/PURPOSE: End-of-life decisions are always difficult and complex, especially in the surgical setting. This study examines the epidemiology of do-not-resuscitate (DNR) orders, and the clinical factors influencing DNR consent. The impact of DNR on treatment and resource use in the surgical intensive-care unit (ICU) is also assessed.

METHODS

This retrospective observational study was performed at National Taiwan University Hospital, a tertiary medical center in Taipei. A total of 14,698 patients were admitted to the surgical ICUs between January 2003 and December 2006. Of these, 13,825 (94.1%) survived to ICU discharge and 873 (5.9%) died. Of those that died, 278 (1.9% of total patients) went home to die due to terminal stage illness and 595 (4.0 % of total patients) died in the ICU. All mortality patients were included in this study.

RESULTS

Yearly DNR rates were all above 65%. The average interval from ICU admission to DNR consent remained stable at 11-13 days, but the interval from DNR consent to death increased over the study period, from 2.0 to 3.5 days. Discussion over DNR was mainly initiated by intensivists. Multivariate logistic regression analysis found that older age (odds ratio, 1.010; p = 0.017) was significantly associated with DNR consent. DNR patients had longer ICU stays, lower fraction of inspired oxygen, and less inotropic infusion, dialysis, transfusion, laboratory examination, and chest radiography, but more use of sedative drugs, analgesics, and nutrition support at the time of death. After DNR, the use of advanced antibiotics, chest radiography, laboratory examination, and transfusion decreased. Inotropic infusion, however, continued to significantly increase.

CONCLUSION

Although DNR was common in our surgical ICU patients, this request was signed late in the ICU course, when therapeutic options had been exhausted. Early initiation of DNR discussion should be promoted to improve end-of-life care and reduce futile treatments in the ICU.

摘要

背景/目的：生命末期的决策总是困难且复杂的，尤其是在外科环境中。本研究旨在探讨不复苏（DNR）医嘱的流行病学，并分析影响 DNR 同意的临床因素。同时，还评估了 DNR 对外科重症监护病房（ICU）治疗和资源利用的影响。

方法

本回顾性观察性研究在台北的台湾大学医院进行。2003 年 1 月至 2006 年 12 月期间，共有 14698 名患者入住外科 ICU。其中，13825 名（94.1%）患者存活至 ICU 出院，873 名（5.9%）患者死亡。在死亡患者中，278 名（占总患者的 1.9%）因终末期疾病而回家死亡，595 名（占总患者的 4.0%）在 ICU 死亡。所有死亡患者均纳入本研究。

结果

每年的 DNR 率均高于 65%。从 ICU 入院到 DNR 同意的平均间隔时间保持稳定，在 11-13 天之间，但从 DNR 同意到死亡的间隔时间在研究期间有所增加，从 2.0 天增加到 3.5 天。DNR 的讨论主要由重症监护医生发起。多变量逻辑回归分析发现，年龄较大（优势比，1.010；p = 0.017）与 DNR 同意显著相关。DNR 患者的 ICU 住院时间更长，吸入氧分数更低，正性肌力药物输注、透析、输血、实验室检查和胸部 X 线检查更少，但在死亡时使用镇静药物、镇痛药和营养支持更多。DNR 后，高级抗生素、胸部 X 线检查、实验室检查和输血的使用减少，但正性肌力药物输注仍显著增加。