Courtwright Andrew M, Rubin Emily, Erler Kimberly S, Bandini Julia I, Zwirner Mary, Cremens M Cornelia, McCoy Thomas H, Robinson Ellen M
Department of Pulmonary and Critical Care, Hospital of the University of Pennsylvania, Philadelphia, PA, USA.
Edwin H. Cassem Optimum Care Committee, Massachusetts General Hospital, Boston, MA, USA.
HEC Forum. 2022 Mar;34(1):73-88. doi: 10.1007/s10730-020-09429-1. Epub 2020 Nov 2.
Critical care society guidelines recommend that ethics committees mediate intractable conflict over potentially inappropriate treatment, including Do Not Resuscitate (DNR) status. There are, however, limited data on cases and circumstances in which ethics consultants recommend not offering cardiopulmonary resuscitation (CPR) despite patient or surrogate requests and whether physicians follow these recommendations. This was a retrospective cohort of all adult patients at a large academic medical center for whom an ethics consult was requested for disagreement over DNR status. Patient demographic predictors of ethics consult outcomes were analyzed. In 42 of the 116 cases (36.2%), the patient or surrogate agreed to the clinician recommended DNR order following ethics consultation. In 72 of 74 (97.3%) of the remaining cases, ethics consultants recommended not offering CPR. Physicians went on to write a DNR order without patient/surrogate consent in 57 (79.2%) of those cases. There were no significant differences in age, race/ethnicity, country of origin, or functional status between patients where a DNR order was and was not placed without consent. Physicians were more likely to place a DNR order for patients believed to be imminently dying (p = 0.007). The median time from DNR order to death was 4 days with a 90-day mortality of 88.2%. In this single-center cohort study, there was no evidence that patient demographic factors affected ethics consultants' recommendation to withhold CPR despite patient/surrogate requests. Physicians were most likely to place a DNR order without consent for imminently dying patients.
重症监护学会指南建议，伦理委员会应对潜在不适当治疗（包括“不要复苏”[DNR]状态）方面的棘手冲突进行调解。然而，关于伦理顾问在患者或代理人提出要求的情况下仍建议不进行心肺复苏（CPR）的病例和情况，以及医生是否遵循这些建议的数据有限。这是一项针对一家大型学术医疗中心所有成年患者的回顾性队列研究，这些患者因对DNR状态存在分歧而被请求进行伦理咨询。分析了伦理咨询结果的患者人口统计学预测因素。在116例病例中的42例（36.2%）中，患者或代理人在伦理咨询后同意了临床医生建议的DNR医嘱。在其余74例病例中的72例（97.3%）中，伦理顾问建议不进行CPR。在其中57例（79.2%）病例中，医生在未经患者/代理人同意的情况下开具了DNR医嘱。在未经同意开具和未开具DNR医嘱的患者之间，年龄、种族/族裔、原籍国或功能状态没有显著差异。医生更有可能为被认为即将死亡的患者开具DNR医嘱（p = 0.007）。从DNR医嘱到死亡的中位时间为4天，90天死亡率为88.2%。在这项单中心队列研究中，没有证据表明患者人口统计学因素会影响伦理顾问不顾患者/代理人要求而建议不进行CPR的决定。医生最有可能在未经同意的情况下为即将死亡的患者开具DNR医嘱。
