Division of Newborn Medicine, Department of Medicine, Boston Children's Hospital, Boston, MA.
Department of Pediatrics, Harvard Medical School, Boston, MA.
Pediatr Crit Care Med. 2018 Jul;19(7):635-642. doi: 10.1097/PCC.0000000000001545.
Studies in adult patients have shown that do-not-resuscitate orders are often associated with decreased medical intervention. In neonatology, this phenomenon has not been investigated, and how do-not-resuscitate orders potentially affect clinical care is unknown.
Retrospective medical record data review and staff survey responses about neonatal ICU do-not-resuscitate orders.
Four academic neonatal ICUs.
Clinical staff members working in each neonatal ICU.
Survey response collection and analysis.
Participating neonatal ICUs had 14-48 beds and 120-870 admissions/yr. Frequency range of do-not-resuscitate orders was 3-11 per year. Two-hundred fifty-seven surveys were completed (46% response). Fifty-nine percent of respondents were nurses; 20% were physicians. Over the 5-year period, 44% and 17% had discussed a do-not-resuscitate order one to five times and greater than or equal to 6 times, respectively. Fifty-seven percent and 22% had cared for one to five and greater than or equal to 6 patients with do-not-resuscitate orders, respectively. Neonatologists, trainees, and nurse practitioners were more likely to report receiving training in discussing do-not-resuscitate orders or caring for such patients compared with registered nurses and respiratory therapists (p < 0.001). Forty-one percent of respondents reported caring for an infant in whom interventions had been withheld after a do-not-resuscitate order had been placed without discussing the specific withholding with the family. Twenty-seven percent had taken care of an infant in whom interventions had been withdrawn under the same circumstances. Participants with previous experiences withholding or withdrawing interventions were more likely to agree that these actions are appropriate (p < 0.001).
Most neonatal ICU staff report experience with do-not-resuscitate orders; however, many, particularly nurses and respiratory therapists, report no training in this area. Variable beliefs with respect to withholding and withdrawing care for patients with do-not-resuscitate orders exist among staff. Because neonatal ICU patients with do-not-resuscitate orders may ultimately survive, withholding or withdrawing interventions may have long-lasting effects, which may or may not coincide with familial intentions.
成人患者的研究表明，拒绝复苏医嘱通常与减少医疗干预有关。在新生儿学中，这一现象尚未得到研究，因此尚不清楚拒绝复苏医嘱如何影响临床护理。
回顾性病历数据审查和工作人员对新生儿重症监护病房拒绝复苏医嘱的调查答复。
四个学术性新生儿重症监护病房。
在每个新生儿重症监护病房工作的临床工作人员。
调查答复的收集和分析。
参与的新生儿重症监护病房有 14-48 张床位，每年有 120-870 例入院。拒绝复苏医嘱的频率范围为每年 3-11 次。完成了 257 份调查（46%的回复率）。59%的答复者是护士；20%是医生。在 5 年期间，分别有 44%和 17%的人讨论过拒绝复苏医嘱 1-5 次和 6 次或更多次。分别有 57%和 22%的人护理过 1-5 名和 6 名或更多名有拒绝复苏医嘱的患者。与注册护士和呼吸治疗师相比，新生儿科医生、受训者和执业护士更有可能报告接受过关于讨论拒绝复苏医嘱或护理此类患者的培训（p<0.001）。41%的答复者报告说，在放置拒绝复苏医嘱后，他们没有与家属讨论具体的停止干预措施，就对一名婴儿停止了干预。27%的人照顾过一名婴儿，在同样的情况下，对其停止了干预。有过停止或撤回干预措施经验的参与者更有可能认为这些措施是恰当的（p<0.001）。
大多数新生儿重症监护病房的工作人员报告有拒绝复苏医嘱的经验；然而，许多人，特别是护士和呼吸治疗师，在这方面没有接受过培训。工作人员对为有拒绝复苏医嘱的患者保留和撤回护理的意见不一。由于新生儿重症监护病房有拒绝复苏医嘱的患者最终可能存活，因此保留或撤回干预措施可能会产生长期影响，这些影响可能与也可能不与家属的意愿相符。
