Department of Surgery, Boston University School of Medicine/Boston Medical Center, Boston, MA.
Department of Surgery, Lahey Hospital and Medical Center, Burlington, MA.
Surgery. 2020 Feb;167(2):292-297. doi: 10.1016/j.surg.2019.07.002. Epub 2019 Aug 16.
Multiple studies have demonstrated that, compared with their full code counterparts, patients with do-not-resuscitate or do-not-intubate status have higher in-hospital and postdischarge mortality than predicted by clinical characteristics alone. We sought to determine whether patient code status affects surgical resident decision making.
We created an online survey that consisted of 4 vignettes, followed by 10 questions regarding decisions on possible diagnostic and therapeutic interventions. All program directors of Accreditation Council for Graduate Medical Education-accredited general surgery residencies were randomized to receive 1 of 2 survey versions that differed only in the code status of the patients described, with requests to distribute the survey to their residents. Responses to each question were based on a Likert scale.
A total of 194 residents completed the survey, 51% of whom were women, and all years of surgical residency were represented. In all vignettes, patient code status influenced perioperative medical decisions, ranging from initiation of dialysis to intensive care unit transfer. In 2 vignettes, it affected decisions to proceed with indicated emergency operations.
When presented with patient scenarios pertaining to clinical decision making, surgical residents tend to assume that patients with a do-not-resuscitate or do-not-intubate code status would prefer to receive less aggressive care overall. As a result, the delivery of appropriate surgical care may be improperly limited unless a patient's goals of care are explicitly stated. It is important for surgical residents to understand that a do-not-resuscitate or do-not-intubate code status should not be interpreted as a "do-not-treat" status.
多项研究表明，与完全代码患者相比，有“不复苏”或“不插管”状态的患者的院内和出院后死亡率高于仅根据临床特征预测的死亡率。我们试图确定患者代码状态是否会影响外科住院医师的决策。
我们创建了一个在线调查，由 4 个案例组成，然后是 10 个关于可能的诊断和治疗干预决策的问题。所有经研究生医学教育认证委员会认证的普通外科住院医师培训计划主任随机分为接受调查的 2 个版本之一，仅在描述的患者代码状态上有所不同，并要求将调查分发给他们的住院医师。每个问题的回答都基于李克特量表。
共有 194 名住院医师完成了调查，其中 51%为女性，涵盖了所有外科住院医师的年份。在所有案例中，患者的代码状态都影响了围手术期的医疗决策，从开始透析到转入重症监护病房不等。在 2 个案例中，它影响了进行有指征的紧急手术的决策。
当面临与临床决策相关的患者情况时，外科住院医师往往认为有“不复苏”或“不插管”代码状态的患者总体上更愿意接受不那么积极的治疗。因此，除非明确说明患者的治疗目标，否则适当的外科治疗可能会被不当限制。外科住院医师必须理解，“不复苏”或“不插管”代码状态不应被解释为“不治疗”状态。
