Department of Emergency Medicine, Taipei Veterans General Hospital, Taipei, Taiwan, ROC.
School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan, ROC.
J Chin Med Assoc. 2021 Jun 1;84(6):633-639. doi: 10.1097/JCMA.0000000000000531.
The primary objective of palliative care, not synonymous with end-of-life (EOL) care, is to align care plans with patient goals, regardless of whether these goals include the pursuit of invasive, life-sustaining procedures, or not. This study determines the differences in EOL care, resource utilization, and outcome in palliative care consultation-eligible emergency department patients with and without do-not-resuscitate (DNR) orders.
This is a retrospective observational study. We consecutively enrolled all the acutely and critically ill emergency department patients eligible for palliative care consultation at the Taipei Veterans General Hospital, a 3000-bed tertiary hospital, from February 1 to July 31, 2018. The outcome measures included in-hospital mortality and EOL care of patients with and without DNR.
A total of 396 patients were included: 159 with and 237 without DNR. Propensity score matching revealed that patients with DNR had significantly shorter duration of hospital stay (404.4 ± 344.4 hours vs 505.2 ± 498.1 hours; p = 0.037), higher in-hospital mortality (54.1% vs 34.6%; p < 0.001), and lower total hospital expenditure (191 239 ± 177 962 NTD vs 249 194 ± 305 629 NTD; p = 0.04). Among patients with DNR, there were fewer deaths in the intensive care unit (30.2% vs 37.0%), more deaths in the hospice ward (16.3% vs 7.4%), more critical discharge to home (9.3% vs 7.4%), more endotracheal removals (3.1% vs 0%; p = 0.024), and more narcotics use (32.7% vs 22.1%; p = 0.018).
The palliative care consultation-eligible emergency department patients with DNR compared with those without DNR experienced worse outcomes, greater pain control, more endotracheal extubations, shorter duration of hospital stay, more critical discharge to home, more hospice referrals, and 23.3% reduction in total expenditure. There were fewer deaths in the ICU among them as well.
缓和医疗的主要目标并非等同于临终关怀（EOL），而是使护理计划与患者的目标保持一致，无论这些目标是否包括采用有创、维持生命的治疗措施。本研究旨在确定在有和没有“不复苏”（DNR）医嘱的情况下，接受缓和医疗咨询的急诊科患者在 EOL 护理、资源利用和结局方面的差异。
这是一项回顾性观察性研究。我们连续纳入了 2018 年 2 月 1 日至 7 月 31 日期间在台北荣民总医院接受缓和医疗咨询的所有符合条件的急性和危重症急诊科患者，该医院是一家拥有 3000 张床位的三级医院。结局指标包括有和无 DNR 患者的院内死亡率和 EOL 护理。
共纳入 396 例患者：159 例有 DNR，237 例无 DNR。倾向评分匹配后发现，有 DNR 的患者住院时间明显更短（404.4±344.4 小时 vs 505.2±498.1 小时；p=0.037），院内死亡率更高（54.1% vs 34.6%；p<0.001），总住院支出更低（191239±177962 新台币 vs 249194±305629 新台币；p=0.04）。在有 DNR 的患者中，重症监护病房（ICU）的死亡率较低（30.2% vs 37.0%），临终关怀病房的死亡率较高（16.3% vs 7.4%），出院至家中的危重症患者较多（9.3% vs 7.4%），气管切开术拔除的患者较多（3.1% vs 0%；p=0.024），使用阿片类药物的患者较多（32.7% vs 22.1%；p=0.018）。
与无 DNR 的患者相比，有 DNR 的接受缓和医疗咨询的急诊科患者的结局更差，疼痛控制更好，气管切开术拔除更多，住院时间更短，出院至家中的危重症患者更多，临终关怀机构转诊更多，总支出减少 23.3%。他们在 ICU 的死亡率也较低。
