长期居住在养老院的居民心肺复苏和不复苏医嘱的稳定性。
Stability of cardiopulmonary resuscitation and do-not-resuscitate orders among long-term nursing home residents.
机构信息
Department of Medicine, Health Policy Research Institute, University of California, Irvine, CA 92697-5800, USA.
出版信息
Med Care. 2013 Aug;51(8):666-72. doi: 10.1097/MLR.0b013e31829742b6.
BACKGROUND
High-quality care for long-term nursing home residents should include discussions and follow-up on patients' end-of-life care wishes. Yet, recent changes to the Minimum Data Set data collection exclude this information from routine assessment of patients mandated by the Centers for Medicare & Medicaid Services, making the provision of high-quality end-of-life care less likely. We examined the stability of cardiopulmonary resuscitation (CPR) and do-not-resuscitate (DNR) orders to offer guidance to policy and care practice developments.
METHODS
We examined changes in DNR status of a national long-term care nursing home cohort, following them for 5 years after admission. A competing risk model was estimated to identify covariates predicting changes from CPR to DNR status and vice versa.
RESULTS
About half the cohort chose DNR at admission and did not change its status. Of those who entered with CPR status, 40% changed to DNR. The most important factors influencing change were hospitalizations and nursing home transfers, followed by race and ethnicity with black race (relative to white) in particular having the largest effect on change. Other individual and nursing home characteristics influenced the likelihood of changing from CPR to DNR as well.
CONCLUSIONS
Long-term nursing home patients who enter with full-code CPR have a high probability of changing their status to DNR during their stay. High-quality care should offer them the opportunity to revisit their choice periodically, documenting changes in end-of-life choices when they occur, thus ensuring that care will match patients' wishes. As the Minimum Data Set plays a prominent role in patients' care, Centers for Medicare & Medicaid Services should consider reinstating information about advance directive in it.
背景
为长期入住养老院的患者提供高质量的护理应包括讨论和跟进患者的临终关怀意愿。然而，最近对最低数据集数据收集的更改排除了医疗保险和医疗补助服务中心规定的对患者进行常规评估的这部分信息，使得提供高质量的临终关怀的可能性降低。我们检查了心肺复苏术（CPR）和不复苏（DNR）医嘱的稳定性，以期为政策和护理实践的发展提供指导。
方法
我们研究了一个全国性长期护理养老院队列的 DNR 状态变化，在他们入院后随访了 5 年。采用竞争风险模型来确定预测从 CPR 到 DNR 状态和反之变化的协变量。
结果
大约一半的队列在入院时选择了 DNR，并且没有改变其状态。在那些入院时处于 CPR 状态的患者中，有 40%转为 DNR。影响变化的最重要因素是住院和养老院转移，其次是种族和民族，其中黑人（相对于白人）的影响最大。其他个人和养老院的特征也影响从 CPR 到 DNR 的转变的可能性。
结论
长期入住养老院的患者，如果入院时选择完全复苏，那么在住院期间改变其状态为 DNR 的可能性很大。高质量的护理应该为他们提供定期重新考虑选择的机会，记录临终关怀选择的变化，从而确保护理符合患者的意愿。由于最低数据集在患者护理中发挥着重要作用，医疗保险和医疗补助服务中心应考虑在其中重新纳入关于预先指示的信息。
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