Department of Neuropsychiatry, Keio University School of Medicine, 35 Shinanomachi, Shinjuku-ku, Tokyo, 160-8582, Japan.
Palliative Care Center, Keio University Hospital, 35 Shinanomachi, Shinjuku-ku, Tokyo, Japan.
BMC Palliat Care. 2021 Jan 6;20(1):6. doi: 10.1186/s12904-020-00698-8.
Patient participation is a key foundation of advance care planning (ACP). However, a patient himself/herself may be left out from sensitive conversations such as end-of-life (EOL) care discussions. The objectives of this study were to investigate patients' participation rate in the discussion of Cardiopulmonary Resuscitation (CPR) / Do-Not-Attempt-Resuscitation (DNAR) order, and in the discussion that the patient is at his/her EOL stage (EOL disclosure), and to explore their associated factors.
This is a retrospective chart review study. The participants were all the patients who were hospitalized and died in a university-affiliated teaching hospital (tertiary medical facility) in central Tokyo, Japan during the period from April 2018 to March 2019. The following patients were excluded: (1) cardiopulmonary arrest on arrival; (2) stillbirth; (3) under 18 years old at the time of death; and (4) refusal by their bereaved family. Presence or absence of CPR/DNAR discussion and EOL disclosure, patients' involvement in those discussions, and their associated factors were investigated.
CPR/DNAR discussions were observed in 336 out of the 358 patients (93.9%). However, 224 of these discussions were carried out without a patient (patient participation rate 33.3%). Male gender (odds ratio (OR) = 2.37 [95% confidence interval (CI) 1.32-4.25]), living alone (OR = 2.51 [1.34-4.71]), and 1 year or more from the date of diagnosis (OR = 1.78 [1.03-3.10]) were associated with higher patient's participation in CPR/DNAR discussions. The EOL disclosure was observed in 341 out of the 358 patients (95.3%). However, 170 of the discussions were carried out without the patient (patient participation rate 50.1%). Patients who died of cancer (OR = 2.41[1.45-4.03]) and patients without mental illness (OR=2.41 [1.11-5.25]) were more likely to participate in EOL disclosure.
In this clinical sample, only up to half of the patients participated in CPR/DNAR discussions and EOL disclosure. Female, living with family, a shorter period from the diagnosis, non-cancer, and mental illness presence are risk factors for lack of patients' participation in CPR/DNAR or EOL discussions. Further attempts to facilitate patients' participation, based on their preference, are warranted.
患者参与是预先医疗指示（ACP）的关键基础。然而，患者本人可能会被排除在敏感的对话之外，例如临终关怀讨论。本研究的目的是调查患者参与心肺复苏术（CPR）/不尝试复苏术（DNAR）医嘱讨论以及患者处于临终阶段（临终披露）讨论的参与率，并探讨其相关因素。
这是一项回顾性病历审查研究。研究对象为 2018 年 4 月至 2019 年 3 月期间在日本东京市中心的一所大学附属医院（三级医疗机构）住院死亡的所有患者。以下患者被排除在外：（1）入院时心肺骤停；（2）死产；（3）死亡时未满 18 岁；（4）其家属拒绝。调查了 CPR/DNAR 讨论的存在或不存在、患者对这些讨论的参与情况以及相关因素。
在 358 名患者中，有 336 名患者进行了 CPR/DNAR 讨论（93.9%）。然而，在这些讨论中，有 224 次没有患者参与（患者参与率为 33.3%）。男性（比值比（OR）=2.37[95%置信区间（CI）1.32-4.25]）、独居（OR=2.51[1.34-4.71]）和诊断后 1 年或以上（OR=1.78[1.03-3.10]）与患者更有可能参与 CPR/DNAR 讨论相关。在 358 名患者中，有 341 名患者进行了临终披露（95.3%）。然而，在这些讨论中有 170 次没有患者参与（患者参与率为 50.1%）。死于癌症的患者（OR=2.41[1.45-4.03]）和没有精神疾病的患者（OR=2.41[1.11-5.25]）更有可能参与临终披露。
在本临床样本中，只有一半左右的患者参与了 CPR/DNAR 讨论和临终披露。女性、与家人同住、从诊断到死亡的时间较短、非癌症和无精神疾病是患者参与 CPR/DNAR 或临终讨论不足的危险因素。有必要根据患者的意愿进一步努力促进患者的参与。
