Department of Epidemiology (M.J.R.), Michigan State University, East Lansing, MI, USA.
Neurology. 2012 Nov 6;79(19):1990-6. doi: 10.1212/WNL.0b013e3182735ced. Epub 2012 Oct 24.
There is concern that do-not-resuscitate (DNR) orders may lead to stroke patients receiving less aggressive treatment and poorer care. Our objectives were to assess the relationship between DNR orders and quality of stroke care among veterans.
A cohort of 3,965 acute ischemic stroke patients admitted to 131 Veterans Health Administration (VHA) facilities in fiscal year 2007 underwent chart abstraction. DNR codes were identified through electronic orders or by documentation of "no code," "no cardiopulmonary resuscitation," or "no resuscitation." Quality of care was measured using 14 inpatient ischemic stroke quality indicators. The association between DNR orders and quality indicators was examined using multivariable logistic regression.
Among 3,965 ischemic stroke patients, 535 (13.5%) had DNR code status, 71% of whom had orders first documented within 1 day of admission. Overall, 4.9% of patients died in-hospital or were discharged to hospice; these outcomes were substantially higher in patients with DNR orders (29.7%), particularly if they were not documented until ≥2 days after admission (47.1%). Patients with DNR orders were significantly older, had more comorbidities, and had greater stroke severity. Following adjustment there were few significant associations between DNR status and the 14 quality indicators, with the exception of lower odds of early ambulation (odds ratio = 0.58, 95% confidence interval = 0.41-0.81) in DNR patients.
DNR orders were associated with limited differences in the select quality indicators investigated, which suggests that DNR orders did not impact quality of care. However, whether DNR orders influence treatment decisions that more directly affect survival remains to be determined.
有观点认为，“不复苏”（DNR）医嘱可能导致中风患者接受的治疗不那么积极，护理质量较差。我们的目的是评估 DNR 医嘱与退伍军人中风护理质量之间的关系。
2007 财年，共有 3965 名急性缺血性中风患者入住 131 家退伍军人健康管理局（VHA）机构，进行了病历摘录。DNR 代码通过电子医嘱或记录“无代码”、“无心肺复苏”或“无复苏”来识别。通过 14 项住院缺血性中风质量指标来衡量护理质量。使用多变量逻辑回归来检查 DNR 医嘱与质量指标之间的关系。
在 3965 名缺血性中风患者中，535 名（13.5%）有 DNR 编码状态，其中 71%的人在入院后 1 天内首次记录医嘱。总体而言，4.9%的患者在院内死亡或出院到临终关怀；有 DNR 医嘱的患者这些结果明显更高（29.7%），尤其是如果医嘱在入院后≥2 天记录（47.1%）。有 DNR 医嘱的患者年龄较大，合并症较多，中风严重程度较高。调整后，DNR 状态与 14 项质量指标之间几乎没有显著关联，除了 DNR 患者早期活动的可能性较低（比值比=0.58，95%置信区间=0.41-0.81）。
DNR 医嘱与所调查的特定质量指标之间存在有限差异，这表明 DNR 医嘱并未影响护理质量。然而，DNR 医嘱是否影响更直接影响生存的治疗决策仍有待确定。
