Department of Surgery, University of Texas Health Science Center, Houston, Texas, USA.
J Trauma Acute Care Surg. 2013 May;74(5):1327-30. doi: 10.1097/TA.0b013e31828c4698.
Despite a well-described association of age and injury with mortality and decreased functional status, inpatient mortality studies have traditionally not included analysis of do not resuscitate (DNR) status. We hypothesized that the increased likelihood of DNR status in older patients alters age-adjusted mortality rates in trauma.
The trauma registry was queried for adult patients admitted to our Level I trauma center (January 2005-December 2008) and divided into eight age groups by decade. Ages 15-44 years were collapsed because of the lack of variation. We compared age, case fatality rate, and DNR status by univariate analysis and trends by χ (p < 0.05).
Of the 15,227 adult patients admitted, 13% were elderly (≥65) and 7% died. DNR status was known in 75% of deaths, and 42% of those had active DNR orders on the chart at time of death. DNR likelihood increased with age (p < 0.05), from 5% to 18%. With DNRs excluded, mortality variability across all ages was markedly diminished (4-7%).
DNR status among trauma patients varies significantly because of inconsistent implementation and meaning between hospitals, and successive decades are more likely to have an active DNR order at time of death. When DNR patients were excluded from mortality analysis, age was minimally associated with an increased risk of death. The inclusion of DNR patients within mortality studies likely skews those analyses, falsely indicating failed resuscitative efforts rather than humane decisions to limit care after injury.
尽管年龄和损伤与死亡率和功能状态下降之间存在明确的关联，但住院患者死亡率研究传统上并未分析不复苏（DNR）状态。我们假设，老年患者 DNR 状态的可能性增加会改变创伤后的年龄调整死亡率。
查询了我们的一级创伤中心（2005 年 1 月至 2008 年 12 月）收治的成年患者的创伤登记处，并按十年分为八个年龄组。由于变化不大，将 15-44 岁年龄组合并。我们通过单因素分析比较了年龄、病死率和 DNR 状态，并通过 χ 趋势检验（p<0.05）进行了比较。
在 15227 名成年患者中，13%为老年人（≥65 岁），7%死亡。75%的死亡患者的 DNR 状态已知，其中 42%的患者在死亡时的图表上有有效的 DNR 医嘱。DNR 可能性随着年龄的增加而增加（p<0.05），从 5%增加到 18%。排除 DNR 患者后，所有年龄段的死亡率变化明显减少（4%-7%）。
由于医院之间实施和意义不一致，创伤患者的 DNR 状态差异很大，并且随着时间的推移，每十年在死亡时更有可能有一个有效的 DNR 医嘱。当 DNR 患者从死亡率分析中排除时，年龄与死亡风险增加的相关性最小。在死亡率研究中包含 DNR 患者可能会使这些分析产生偏差，错误地表明复苏努力失败，而不是在受伤后限制护理的人道决策。
