Sasaki Akinori, Hiraoka Eiji, Homma Yosuke, Takahashi Osamu, Norisue Yasuhiro, Kawai Koji, Fujitani Shigeki
Department of Internal Medicine.
Department of Emergency Medicine, Tokyo Bay Urayasu Ichikawa Medical Center, Urayasu City, Chiba.
Int J Gen Med. 2017 Jul 14;10:207-214. doi: 10.2147/IJGM.S136921. eCollection 2017.
Code status discussion is associated with a decrease in invasive procedures among terminally ill cancer patients. We investigated the association between code status discussion on admission and incidence of invasive procedures, cardiopulmonary resuscitation (CPR), and opioid use among inpatients with advanced stages of cancer and noncancer diseases.
We performed a retrospective cohort study in a single center, Ito Municipal Hospital, Japan. Participants were patients who were admitted to the Department of Internal Medicine between October 1, 2013 and August 30, 2015, with advanced-stage cancer and noncancer. We collected demographic data and inquired the presence or absence of code status discussion within 24 hours of admission and whether invasive procedures, including central venous catheter placement, intubation with mechanical ventilation, and CPR for cardiac arrest, and opioid treatment were performed. We investigated the factors associated with CPR events by using multivariate logistic regression analysis.
Among the total 232 patients, code status was discussed with 115 patients on admission, of which 114 (99.1%) patients had do-not-resuscitate (DNR) orders. The code status was not discussed with the remaining 117 patients on admission, of which 69 (59%) patients had subsequent code status discussion with resultant DNR orders. Code status discussion on admission decreased the incidence of central venous catheter placement, intubation with mechanical ventilation, and CPR in both cancer and noncancer patients. It tended to increase the rate of opioid use. Code status discussion on admission was the only factor associated with the decreased use of CPR (<0.001, odds ratio =0.03, 95% CI =0.004-0.21), which was found by using multivariate logistic regression analysis.
Code status discussion on admission is associated with a decrease in invasive procedures and CPR in cancer and noncancer patients. Physicians should be educated about code status discussion to improve end-of-life care.
临终状态讨论与晚期癌症患者侵入性操作的减少有关。我们调查了入院时的临终状态讨论与晚期癌症和非癌症疾病住院患者侵入性操作、心肺复苏（CPR）及阿片类药物使用发生率之间的关联。
我们在日本伊东市立医院这一单一中心进行了一项回顾性队列研究。参与者为2013年10月1日至2015年8月30日期间入住内科的晚期癌症和非癌症患者。我们收集了人口统计学数据，并询问了入院后24小时内是否进行了临终状态讨论，以及是否进行了包括中心静脉导管置入、机械通气插管和心脏骤停时的心肺复苏等侵入性操作及阿片类药物治疗。我们通过多因素逻辑回归分析研究了与心肺复苏事件相关的因素。
在总共232例患者中，115例患者在入院时进行了临终状态讨论，其中114例（99.1%）患者有不进行心肺复苏（DNR）医嘱。其余117例患者入院时未进行临终状态讨论，其中69例（59%）患者随后进行了临终状态讨论并产生了DNR医嘱。入院时的临终状态讨论降低了癌症和非癌症患者中心静脉导管置入、机械通气插管和心肺复苏的发生率。它倾向于提高阿片类药物的使用率。通过多因素逻辑回归分析发现，入院时的临终状态讨论是与心肺复苏使用减少相关的唯一因素（<0.001，比值比=0.03，95%可信区间=0.004-0.21）。
入院时的临终状态讨论与癌症和非癌症患者侵入性操作及心肺复苏的减少有关。应教育医生进行临终状态讨论以改善临终关怀。
