Mirarchi Ferdinando L, Costello Erin, Puller Justin, Cooney Timothy, Kottkamp Nathan
University of Pittsburgh Medical Center (UPMC) Hamot, Erie, Pennsylvania, USA.
J Emerg Med. 2012 May;42(5):511-20. doi: 10.1016/j.jemermed.2011.07.015. Epub 2011 Nov 17.
Concern exists that living wills are misinterpreted and may result in compromised patient safety.
To determine whether adding code status to a living will improves understanding and treatment decisions.
An Internet survey was conducted of General Surgery, and Family, Internal, and Emergency Medicine residencies between May and December 2009. The survey posed a fictitious living will with and without additional clarification in the form of code status. An emergent patient care scenario was then presented that included medical history and signs/symptoms. Respondents were asked to assign a code status and choose appropriate intervention. Questions were formatted as dichotomous responses. Correct response rate was based on legal statute. Significance of changes in response due to the addition of either clinical context (past medical history/signs/symptoms) or code status was assessed by contingency table analysis.
Seven hundred sixty-eight faculty and residents at accredited training centers in 34 states responded. At baseline, 22% denoted "full code" as the code status for a typical living will, and 36% equated "full care" with a code status DNR. Adding clinical context improved correct responses by 21%. Specifying code status further improved correct interpretation by 28% to 34%. Treatment decisions were either improved 12-17% by adding code status ("Full Code," "Hospice Care") or worsened 22% ("DNR").
Misunderstanding of advance directives is a nationwide problem. Addition of code status may help to resolve the problem. Further research is required to ensure safety, understanding, and appropriate care to patients.
人们担心生前预嘱会被误解，可能导致患者安全受到损害。
确定在生前预嘱中增加代码状态是否能提高理解和治疗决策水平。
2009年5月至12月对普通外科、家庭医学、内科和急诊医学住院医师进行了一项网络调查。该调查提出了一份虚构的生前预嘱，有或没有以代码状态形式的额外说明。然后给出一个紧急患者护理场景，包括病史和体征/症状。要求受访者指定代码状态并选择适当的干预措施。问题采用二分法回答。正确回答率基于法律法规。通过列联表分析评估由于增加临床背景（既往病史/体征/症状）或代码状态而导致的回答变化的显著性。
来自34个州认可培训中心的768名教员和住院医师做出了回应。在基线时，22%的人将“完全复苏”指定为典型生前预嘱的代码状态，36%的人将“全面护理”等同于“不要复苏”的代码状态。增加临床背景使正确回答率提高了21%。明确代码状态进一步将正确解释提高了28%至34%。通过增加代码状态（“完全复苏”、“临终关怀”），治疗决策改善了12 - 17%，或者恶化了22%（“不要复苏”）。
对预先指示的误解是一个全国性问题。增加代码状态可能有助于解决该问题。需要进一步研究以确保患者的安全、理解和适当护理。
