1Division of Pulmonary, Critical Care and Sleep Medicine, Department of Internal Medicine, University of Texas Health Science Center at Houston, Houston, TX. 2Section of General Internal Medicine, Department of Internal Medicine, Wake Forest School of Medicine, Winston-Salem, NC. 3Department of Pediatrics, Center for Clinical Research and Evidence-Based Medicine, University of Texas Health Science Center at Houston, Houston, TX.
Crit Care Med. 2014 Feb;42(2):357-61. doi: 10.1097/CCM.0b013e3182a276c9.
Withdrawal or withholding of life-sustaining therapies precedes most deaths in the modern ICU. As goals of care for critically ill patients change from curative to palliative, this transition often occurs abruptly, but a slower more staggered approach may also be used. One such approach is "no escalation of care", often the first step in this transition at the end-of-life. We aimed to determine the prevalence of no escalation of care designation for ICU decedents and identify which interventions are involved.
We performed a retrospective medical record review of all patients who died over a two year period. Records with documentation of no escalation of care in physician orders or progress notes, or other instructions suggesting sequential or selective limitation of interventions were included.
Sixteen bed medical ICU at a single large academic hospital.
None.
Of a total of 310 ICU decedents, 95 (30%) had a no escalation of care designation before death. Hemodialysis, vasopressors, and blood transfusions were the interventions more likely to be withheld. For ongoing therapies, hemodialysis, blood transfusions, and antibiotics were more likely to be withdrawn. Mechanical ventilation, hydration, and nutrition were less likely to be withheld or withdrawn. A minority had a palliative care consult (15%) or ethics consult (4%) while in the ICU. Time from no escalation of care designation to death averaged 0.8 days (range, 0-5 d).
No escalation of care designation occurs in a significant proportion of ICU decedents shortly before death. Some interventions are more likely to be limited than others using a no escalation of care approach.
在现代 ICU 中，维持生命治疗的撤回或停止往往先于大多数死亡。随着危重病患者治疗目标从治愈转向姑息治疗，这种转变通常是突然发生的，但也可以采用更缓慢、更渐进的方法。其中一种方法是“不升级治疗”，这通常是生命末期这一转变的第一步。我们旨在确定 ICU 死亡患者中不升级治疗指定的流行率，并确定涉及哪些干预措施。
我们对两年内所有死亡患者的病历进行了回顾性医学记录审查。记录中有医生医嘱或病程记录中不升级治疗的记录，或其他表明序贯或选择性限制干预措施的说明，则包括在内。
一家大型学术医院的 16 张病床的医学 ICU。
无。
在总共 310 名 ICU 死亡患者中，有 95 名（30%）在死亡前有不升级治疗的指定。血液透析、血管加压素和输血是更有可能被停止的干预措施。对于正在进行的治疗，血液透析、输血和抗生素更有可能被撤回。机械通气、补液和营养的可能性较小。少数患者在 ICU 期间接受了姑息治疗咨询（15%）或伦理学咨询（4%）。从不升级治疗指定到死亡的平均时间为 0.8 天（范围，0-5 天）。
在死亡前不久，相当一部分 ICU 死亡患者有不升级治疗的指定。使用不升级治疗方法，某些干预措施比其他干预措施更有可能受到限制。
