Division of Geriatrics and Gerontology, Weill Medical College, Cornell University, 525 E 68th Street, Box 39, New York, NY 10065, USA.
J Gen Intern Med. 2011 Jul;26(7):791-7. doi: 10.1007/s11606-011-1632-x. Epub 2011 Feb 1.
Do-not-resuscitate (DNR) orders have been in use in hospitals nationwide for over 20 years. Nonetheless, as currently implemented, they fail to adequately fulfill their two intended purposes--to support patient autonomy and to prevent non-beneficial interventions. These failures lead to serious consequences. Patients are deprived of the opportunity to make informed decisions regarding resuscitation, and CPR is performed on patients who would have wanted it withheld or are harmed by the procedure. This article highlights the persistent problems with today's use of inpatient DNR orders, i.e., DNR discussions do not occur frequently enough and occur too late in the course of patients' illnesses to allow their participation in resuscitation decisions. Furthermore, many physicians fail to provide adequate information to allow patients or surrogates to make informed decisions and inappropriately extrapolate DNR orders to limit other treatments. Because these failings are primarily due to systemic factors that result in deficient physician behaviors, we propose strategies to target these factors including changing the hospital culture, reforming hospital policies on DNR discussions, mandating provider communication skills training, and using financial incentives. These strategies could help overcome existing barriers to proper DNR discussions and align the use of DNR orders closer to their intended purposes of supporting patient self-determination and avoiding non-beneficial interventions at the end of life.
“不复苏”（Do-not-resuscitate，DNR）医嘱在全国的医院中已经使用了 20 多年。然而，就目前的实施情况来看，它们未能充分实现其两个预期目的——支持患者自主权和防止无益的干预。这些失败导致了严重的后果。患者被剥夺了就复苏做出明智决策的机会，而 CPR 则在那些希望停止或因该程序而受到伤害的患者身上进行。本文强调了当今使用住院患者 DNR 医嘱时存在的持续问题，即 DNR 讨论不够频繁，而且在患者疾病过程中发生得太晚，无法让他们参与复苏决策。此外，许多医生未能提供足够的信息，以使患者或代理人能够做出明智的决策，并不适当地将 DNR 医嘱推断为限制其他治疗。由于这些失败主要是由于系统因素导致医生行为不足，我们提出了针对这些因素的策略，包括改变医院文化、改革医院关于 DNR 讨论的政策、强制进行医疗服务提供者沟通技巧培训，以及使用经济激励措施。这些策略可以帮助克服适当的 DNR 讨论中存在的现有障碍，并使 DNR 医嘱的使用更符合其支持患者自主决策和避免生命末期无益干预的预期目的。
