Department of Medicine, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada; Bruyère Research Institute, Ottawa, Ontario, Canada; Institute for Clinical Evaluative Sciences, Population Health and Primary Care, Ottawa, Ontario, Canada.
Department of Medicine, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada; Institute for Clinical Evaluative Sciences, Population Health and Primary Care, Ottawa, Ontario, Canada.
J Am Med Dir Assoc. 2019 Sep;20(9):1169-1174.e1. doi: 10.1016/j.jamda.2019.02.017. Epub 2019 Apr 8.
To describe the rate of do-not-resuscitate (DNR) and do-not-hospitalize (DNH) orders among residents newly admitted into long-term care homes. We also assessed the association between DNR and DNH orders with hospital admissions, deaths in hospital, and survival.
A retrospective cohort study.
Admissions in all 640 publicly funded long-term care homes in Ontario, Canada, between January 1, 2010 and March 1, 2012 (n = 49,390).
We examined if a DNR and/or DNH was recorded on resident's admission assessment. All residents were followed until death, discharge, or end of study to ascertain rates of several outcomes, including death and hospitalization, controlling for resident characteristics.
Upon admission, 60.7% of residents were recorded to have a DNR and 14.8% a DNH order. Those who were older, female, widowed, lived in rural facilities, lived in higher income neighborhoods prior to entry, had higher health instability or cognitive impairment, and spoke English or French were more likely to receive a DNR or DNH. Survival time was only slightly shorter for those with a DNR and DNH with a mean of 145 and 133 days, respectively, vs 160 and 153 days for those without a DNR and DNH. After controlling for age, sex, rurality, neighborhood income, marital status, health instability, cognitive performance score, and multimorbidity, DNR and DNH were associated with an odds ratio of 0.57 [95% confidence interval (CI) 0.53-0.62] and 0.41 (95% CI 0.37-0.46) for dying in hospital, respectively. Those with a DNR and DNH, after adjustment, had an incidence rate ratio of 0.87 (95% CI 0.83-0.90) and 0.70 (95% CI 0.67-0.73), respectively, days spent in hospital.
This study outlines identifiable factors influencing whether residents have a DNR and/or DNH order upon admission. Both orders led to lower rates, but not absolute avoidance, of hospitalizations near and at death.
描述新入住长期护理院的居民的不复苏（DNR）和不住院（DNH）医嘱的比率。我们还评估了 DNR 和 DNH 医嘱与住院、院内死亡和生存之间的关联。
回顾性队列研究。
2010 年 1 月 1 日至 2012 年 3 月 1 日期间，加拿大安大略省所有 640 家公共资助的长期护理院的入院患者（n=49390）。
我们检查了居民入院评估时是否记录了 DNR 和/或 DNH。所有居民均随访至死亡、出院或研究结束，以确定包括死亡和住院在内的多种结局的发生率，同时控制了居民特征。
入院时，60.7%的患者记录有 DNR 医嘱，14.8%的患者记录有 DNH 医嘱。年龄较大、女性、丧偶、居住在农村设施、入院前居住在高收入社区、健康不稳定或认知障碍程度较高、以及讲英语或法语的患者更有可能接受 DNR 或 DNH 医嘱。有 DNR 和 DNH 的患者的生存时间仅略短，分别为平均 145 天和 133 天，而无 DNR 和 DNH 的患者的生存时间分别为 160 天和 153 天。在控制了年龄、性别、农村、社区收入、婚姻状况、健康不稳定、认知表现评分和多种合并症后，DNR 和 DNH 与院内死亡的比值比分别为 0.57（95%置信区间 [CI] 0.53-0.62）和 0.41（95% CI 0.37-0.46）。调整后，有 DNR 和 DNH 的患者住院的发病率比分别为 0.87（95% CI 0.83-0.90）和 0.70（95% CI 0.67-0.73）。
本研究概述了影响居民入院时是否有 DNR 和/或 DNH 医嘱的可识别因素。这两种医嘱都降低了，但并没有完全避免了临近死亡和死亡时的住院率。
