Fuchs Lior, Anstey Matthew, Feng Mengling, Toledano Ronen, Kogan Slava, Howell Michael D, Clardy Peter, Celi Leo, Talmor Daniel, Novack Victor
1Clinical Research Center, Soroka University Medical Center and Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer-Sheva, Israel. 2Department of Anesthesia, Critical Care and Pain Medicine, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, MA. 3Intensive Care Unit, Sir Charles Gairdner Hospital, Nedlands, Western Australia. 4The Harvard-MIT Division of Health Sciences & Technology, Massachusetts Institute of Technology, Cambridge, MA. 5Institute for Infocomm Research, Agency for Science, Technology and Research, Singapore. 6Center for Quality and the Section of Pulmonary and Critical Care, University of Chicago, Chicago, IL. 7Department of Pulmonary and Critical Care Medicine, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, MA.
Crit Care Med. 2017 Jun;45(6):1019-1027. doi: 10.1097/CCM.0000000000002312.
We quantified the 28-day mortality effect of preexisting do-not-resuscitate orders in ICUs.
Longitudinal, retrospective study of patients admitted to five ICUs at a tertiary university medical center (Beth Israel Deaconess Medical Center, BIDMC, Boston, MA) between 2001 and 2008.
None.
Two cohorts were defined: patients with do not resuscitate advance directives on day 1 of ICU admission and a control group comprising patients with no limitations of level of care on ICU day 1 (full code).
The primary outcome was mortality at 28 days after ICU admission. Of 19,007 ICU patients, 1,239 patients (6.5%) had a do-not-resuscitate order on the first day of ICU admission and survived 48 hours in the ICU. We matched those do-not-resuscitate patients with 2,402 patients with full-code status. Twenty-eight day and 1-year mortality were both significantly higher in the do-not-resuscitate group (33.9% vs 18.4% and 60.7% vs 40.2%; p < 0.001, respectively).
Do-not-resuscitate status is an independent risk factor for ICU mortality. This may reflect severity of illness not captured by other clinical factors, but the perceptions of the treating team related to do-not-resuscitate status could also be causally responsible for increased mortality in patients with do-not-resuscitate status.
我们对重症监护病房（ICU）中预先存在的不进行心肺复苏（DNR）医嘱对28天死亡率的影响进行了量化。
对2001年至2008年间在一所三级大学医学中心（马萨诸塞州波士顿市贝斯以色列女执事医疗中心，BIDMC）的五个ICU住院的患者进行纵向回顾性研究。
无。
定义了两个队列：入住ICU第1天有不进行心肺复苏预先指示的患者，以及一个对照组，该对照组由入住ICU第1天护理级别无限制（完全复苏）的患者组成。
主要结局是ICU入院后28天的死亡率。在19,007名ICU患者中，1,239名患者（6.5%）在入住ICU的第一天有不进行心肺复苏医嘱且在ICU存活了48小时。我们将那些不进行心肺复苏的患者与2,402名完全复苏状态的患者进行匹配。不进行心肺复苏组的28天和1年死亡率均显著更高（分别为33.9%对18.4%和60.7%对40.2%；p均<0.001）。
不进行心肺复苏状态是ICU死亡率的独立危险因素。这可能反映了其他临床因素未捕捉到的疾病严重程度，但治疗团队对不进行心肺复苏状态的认知也可能是导致不进行心肺复苏状态患者死亡率增加的原因。
