Mpody Christian, Humphrey Lisa, Kim Stephani, Tobias Joseph D, Nafiu Olubukola O
Department of Anesthesiology and Pain Medicine, Nationwide Children's Hospital, Columbus, Ohio, USA.
Division of Palliative Care, Department of Pediatrics, The Ohio State University, Columbus, Ohio, USA.
J Palliat Med. 2021 Jan;24(1):71-76. doi: 10.1089/jpm.2020.0053. Epub 2020 Jun 15.
Very few studies have investigated the racial differences in do-not-resuscitate (DNR) orders in children, and these studies are limited to oncological cases. We aim to characterize the racial difference in DNR orders among U.S. pediatric surgical patients. We retrospectively evaluated the mortality of all children who underwent an inpatient surgery between 2012 and 2017 from the National Surgical Quality Improvement Program. We used log-binomial models to estimate the relative risk (RR) and 95% confidence interval (CI) of DNR use comparing white with African American (AA) children. To estimate the risk-adjusted difference in DNR orders, we controlled the analyses for age, prematurity status, emergent case status, American Society of Anesthesiologists class, year of operation, surgical specialty, and surgical complexity. Between 2012 and 2017, a total of 276,917 children underwent inpatient surgery, of whom 0.8% ( = 1601) died within 30 days of operation. Of the 1601 mortality cases, we retained 1212 children who were of either AA (26.0%, = 350) or white (63.9%, = 862) race. Most children were neonates, had an American Society of Anesthesiologists class ≥4 (70.0%, = 811), and developed one or more postoperative complications (68.7%, = 833). Overall, AA children were more likely to be neonates at the time of surgery (42.0% vs. 40.3%, < 0.001), to be premature (66.3% vs. 49.0%, < 0.001), and develop one or more postoperative complications (73.7% vs. 66.7%, = 0.017). White children were three times more likely to have a DNR order than their AA peers (adjusted RR: 3.01, 95% CI: 1.09-8.56, = 0.044). Among pediatric surgical patients in the United States, children of white race were three times more likely to have a DNR order in place than their AA peers despite the latter being "sicker" and more likely to develop postoperative complications. The mechanisms underlying this racial difference deserve further elucidation to improve shared decision making and goal-concordant care.
极少有研究调查儿童“不要复苏”（DNR）医嘱中的种族差异，且这些研究仅限于肿瘤病例。我们旨在描述美国儿科手术患者中DNR医嘱的种族差异。我们回顾性评估了2012年至2017年期间从国家外科质量改进计划中接受住院手术的所有儿童的死亡率。我们使用对数二项式模型来估计白人儿童与非裔美国（AA）儿童使用DNR的相对风险（RR）和95%置信区间（CI）。为了估计DNR医嘱的风险调整差异，我们在分析中控制了年龄、早产状态、急诊病例状态、美国麻醉医师协会分级、手术年份、外科专科和手术复杂性。2012年至2017年期间，共有276,917名儿童接受了住院手术，其中0.8%（n = 1601）在术后30天内死亡。在这1601例死亡病例中，我们纳入了1212名非裔美国（26.0%，n = 350）或白人（63.9%，n = 862）儿童。大多数儿童为新生儿，美国麻醉医师协会分级≥4（70.0%，n = 811），且出现一种或多种术后并发症（68.7%，n = 833）。总体而言，非裔美国儿童在手术时更有可能是新生儿（42.0%对40.3%，P < 0.001），更有可能早产（66.3%对49.0%，P < 0.001），且更有可能出现一种或多种术后并发症（73.7%对66.7%，P = 0.017）。白人儿童拥有DNR医嘱的可能性是非裔美国同龄人三倍（调整后RR：3.01，95%CI：1.09 - 8.56，P = 0.044）。在美国儿科手术患者中，白人儿童拥有DNR医嘱的可能性是非裔美国同龄人三倍，尽管后者病情“更重”且更有可能出现术后并发症。这种种族差异背后的机制值得进一步阐明，以改善共同决策和目标一致的护理。
