时机至关重要：重症监护病房中的早期不复苏医嘱与患者结局。
Timing is everything: Early do-not-resuscitate orders in the intensive care unit and patient outcomes.
机构信息
Center for Research on End-of-Life Care, Weill Cornell Medicine, New York, New York, United State of America.
Department of Medicine, Weill Cornell Medicine, New York, New York, United State of America.
出版信息
PLoS One. 2020 Feb 18;15(2):e0227971. doi: 10.1371/journal.pone.0227971. eCollection 2020.
BACKGROUND
The use of Do-Not-Resuscitate (DNR) orders has increased but many are placed late in the dying process. This study is to determine the association between the timing of DNR order placement in the intensive care unit (ICU) and nurses' perceptions of patients' distress and quality of death.
METHODS
200 ICU patients and the nurses (n = 83) who took care of them during their last week of life were enrolled from the medical ICU and cardiac care unit of New York Presbyterian Hospital/Weill Cornell Medicine in Manhattan and the surgical ICU at the Brigham and Women's Hospital in Boston. Nurses were interviewed about their perceptions of the patients' quality of death using validated measures. Patients were divided into 3 groups-no DNR, early DNR, late DNR placement during the patient's final ICU stay. Logistic regression analyses modeled perceived patient quality of life as a function of timing of DNR order placement. Patient's comorbidities, length of ICU stay, and procedures were also included in the model.
RESULTS
59 patients (29.5%) had a DNR placed within 48 hours of ICU admission (early DNR), 110 (55%) placed after 48 hours of ICU admission (late DNR), and 31 (15.5%) had no DNR order placed. Compared to patients without DNR orders, those with an early but not late DNR order placement had significantly fewer non-beneficial procedures and lower odds of being rated by nurses as not being at peace (Adjusted Odds Ratio namely AOR = 0.30; [CI = 0.09-0.94]), and experiencing worst possible death (AOR = 0.31; [CI = 0.1-0.94]) before controlling for procedures; and consistent significance in severe suffering (AOR = 0.34; [CI = 0.12-0.96]), and experiencing a severe loss of dignity (AOR = 0.33; [CI = 0.12-0.94]), controlling for non-beneficial procedures.
CONCLUSIONS
Placement of DNR orders within the first 48 hours of the terminal ICU admission was associated with fewer non-beneficial procedures and less perceived suffering and loss of dignity, lower odds of being not at peace and of having the worst possible death.
背景
不复苏（DNR）医嘱的使用有所增加，但许多医嘱都是在临终过程中晚期下达的。本研究旨在确定重症监护病房（ICU）中 DNR 医嘱下达时间与护士对患者痛苦和死亡质量的感知之间的关联。
方法
200 名 ICU 患者及其在生命最后一周接受护理的护士（n = 83）来自曼哈顿纽约长老会医院/威尔康奈尔医学院的内科 ICU 和心脏护理病房以及波士顿布莱根妇女医院的外科 ICU。护士使用经过验证的措施对他们对患者死亡质量的看法进行了访谈。患者分为三组 - 无 DNR、早期 DNR、晚期 DNR 在患者最后一次 ICU 住院期间下达。逻辑回归分析将感知到的患者生活质量作为 DNR 医嘱下达时间的函数建模。还将患者的合并症、ICU 住院时间和程序纳入模型。
结果
59 名患者（29.5%）在 ICU 入院后 48 小时内下达了 DNR（早期 DNR），110 名患者（55%）在 ICU 入院后 48 小时后下达了 DNR（晚期 DNR），31 名患者（15.5%）没有下达 DNR 医嘱。与没有 DNR 医嘱的患者相比，早期但不是晚期 DNR 医嘱下达的患者接受非有益程序的次数明显减少，并且被护士评为不安宁的可能性较低（调整后的优势比即 AOR = 0.30；[CI = 0.09-0.94]），并且在没有控制程序的情况下，经历最糟糕的死亡可能性（AOR = 0.31；[CI = 0.1-0.94]）；并且在严重痛苦（AOR = 0.34；[CI = 0.12-0.96]）和严重失去尊严（AOR = 0.33；[CI = 0.12-0.94]）方面具有一致的显着性，控制非有益程序。
结论
在 ICU 入住的头 48 小时内下达 DNR 医嘱与较少的非有益程序和较少的感知痛苦和尊严丧失、不安宁和最坏死亡的可能性较低有关。
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