Chen Yen-Yuan, Gordon Nahida H, Connors Alfred F, Garland Allan, Chang Shan-Chwen, Youngner Stuart J
BMC Med. 2014 Aug 29;12:146. doi: 10.1186/s12916-014-0146-x.
Do-Not-Resuscitate (DNR) patients tend to receive less medical care after the order is written. To provide a clearer approach, the Ohio Department of Health adopted the Do-Not-Resuscitate law in 1998, indicating two distinct protocols of DNR orders that allow DNR patients to choose the medical care: DNR Comfort Care (DNRCC), implying DNRCC patients receive only comfort care after the order is written; and DNR Comfort Care-Arrest (DNRCC-Arrest), implying that DNRCC-Arrest patients are eligible to receive aggressive interventions until cardiac or respiratory arrest. The aim of this study was to examine the medical care provided to patients with these two distinct protocols of DNR orders.
Data were collected from August 2002 to December 2005 at a medical intensive care unit in a university-affiliated teaching hospital. In total, 188 DNRCC-Arrest patients, 88 DNRCC patients, and 2,051 non-DNR patients were included. Propensity score matching using multivariate logistic regression was used to balance the confounding variables between the 188 DNRCC-Arrest and 2,051 non-DNR patients, and between the 88 DNRCC and 2,051 non-DNR patients. The daily cost of intensive care unit (ICU) stay, the daily cost of hospital stay, the daily discretionary cost of ICU stay, six aggressive interventions, and three comfort care measures were used to indicate the medical care patients received. The association of each continuous variable and categorical variable with having a DNR order written was analyzed using Student's t-test and the χ2 test, respectively. The six aggressive interventions and three comfort care measures performed before and after the order was initiated were compared using McNemar's test.
DNRCC patients received significantly fewer aggressive interventions and more comfort care after the order was initiated. By contrast, for DNRCC-Arrest patients, the six aggressive interventions provided were not significantly decreased, but the three comfort care measures were significantly increased after the order was initiated. In addition, the three medical costs were not significantly different between DNRCC and non-DNR patients, or between DNRCC-Arrest and non-DNR patients.
When medical care provided to DNR patients is clearly indicated, healthcare professionals will provide the medical care determined by patient/surrogate decision-makers and healthcare professionals, rather than blindly decreasing medical care.
“不要复苏”（DNR）患者在医嘱下达后往往接受较少的医疗护理。为提供更清晰的方法，俄亥俄州卫生部于1998年通过了“不要复苏”法，该法规定了两种不同的DNR医嘱方案，允许DNR患者选择医疗护理：DNR舒适护理（DNRCC），意味着DNRCC患者在医嘱下达后仅接受舒适护理；以及DNR舒适护理-心脏骤停（DNRCC-Arrest），意味着DNRCC-Arrest患者在心脏或呼吸骤停前有资格接受积极干预。本研究的目的是检查为具有这两种不同DNR医嘱方案的患者提供的医疗护理。
数据于2002年8月至2005年12月在一所大学附属教学医院的医疗重症监护病房收集。总共纳入了188例DNRCC-Arrest患者、88例DNRCC患者和2051例非DNR患者。使用多变量逻辑回归进行倾向得分匹配，以平衡188例DNRCC-Arrest患者与2051例非DNR患者之间以及88例DNRCC患者与2051例非DNR患者之间的混杂变量。重症监护病房（ICU）住院每日费用、住院每日费用、ICU住院每日可自由支配费用、六种积极干预措施和三种舒适护理措施用于表明患者接受的医疗护理。分别使用学生t检验和χ2检验分析每个连续变量和分类变量与下达DNR医嘱之间的关联。使用McNemar检验比较医嘱下达前后进行的六种积极干预措施和三种舒适护理措施。
DNRCC患者在医嘱下达后接受的积极干预措施明显减少，舒适护理明显增多。相比之下，对于DNRCC-Arrest患者，提供的六种积极干预措施没有明显减少，但医嘱下达后三种舒适护理措施明显增加。此外，DNRCC患者与非DNR患者之间以及DNRCC-Arrest患者与非DNR患者之间的三项医疗费用没有显著差异。
当明确规定为DNR患者提供的医疗护理时，医疗保健专业人员将提供由患者/替代决策者和医疗保健专业人员确定的医疗护理，而不是盲目减少医疗护理。
