Marcia Lobsang, Ashman Zane W, Pillado Eric B, Kim Dennis Y, Plurad David S
Division of Trauma/Acute Care Surgery/Surgical Critical Care, Department of Surgery, Harbor-UCLA Medical Center, Torrance, California, USA.
Am Surg. 2018 Oct 1;84(10):1565-1569. doi: 10.1177/000313481808401005.
Formal communication of end-of-life preferences is crucial among patients with metastatic cancer. Our objective is to describe the prevalence of advance directives (AD) and do-not-resuscitate (DNR) orders among stage IV cancer patients with acute care surgery consultations, and the associated outcomes. This is a single institution retrospective review over an eight-year period. Two hundred and three patients were identified; mean age was 55.3 ± 11.4 years and 48.8 per cent were male. Fifty (24.6%) patients underwent exploratory surgery. Nineteen (10.6%) patients had another type of surgery. Twenty-one (10.3%) patients had a DNR order, and none had an AD on-admission. Fifty-four (26.6%) patients had a DNR order placed and four (2%) patients completed an AD postadmission. DNR postadmission was associated with the highest mortality at 42.6 per cent compared with 14.3 per cent for DNR on-admission and 1.56 per cent for full-code patients ( < 0.001). Compared with patients that remained full-code and those with DNR on-admission, DNR postadmission was associated with longer length of stay (19.6 days; < 0.001) and ICU length of stay (7.72 days; < 0.001). The prevalence of AD and DNR orders among stage IV cancer patients is low. The higher in-hospital mortality of patients with DNR postadmission reflects the use of DNR orders during clinical decline.
对于转移性癌症患者而言，正式沟通临终意愿至关重要。我们的目的是描述在接受急性护理手术会诊的IV期癌症患者中，预立医疗指示（AD）和不进行心肺复苏（DNR）医嘱的发生率及其相关结果。这是一项在八年期间进行的单机构回顾性研究。共确定了203例患者；平均年龄为55.3±11.4岁，48.8%为男性。50例（24.6%）患者接受了 exploratory surgery（此处原文有误，推测可能是“探查性手术”，但需确认）。19例（10.6%）患者接受了其他类型的手术。21例（10.3%）患者有DNR医嘱，入院时无患者有预立医疗指示。54例（26.6%）患者在入院后下达了DNR医嘱，4例（2%）患者在入院后完成了预立医疗指示。入院后下达DNR医嘱的患者死亡率最高，为42.6%，而入院时即有DNR医嘱的患者死亡率为14.3%，进行完全复苏的患者死亡率为1.56%（<0.001）。与维持完全复苏状态的患者和入院时即有DNR医嘱的患者相比，入院后下达DNR医嘱的患者住院时间更长（19.6天；<0.001），重症监护病房住院时间更长（7.72天；<0.001）。IV期癌症患者中预立医疗指示和DNR医嘱的发生率较低。入院后下达DNR医嘱的患者院内死亡率较高，这反映了在临床病情恶化期间使用DNR医嘱的情况。
