Kellogg F R, Ramos A
Dept of Community Medicine, St. Vincent's Hospital, New York, NY 10011.
J Am Geriatr Soc. 1995 Feb;43(2):113-21. doi: 10.1111/j.1532-5415.1995.tb06375.x.
To examine the clinical utility of prehospital code status discussions in a nursing home (NH) setting and the health care outcomes of the decisions made. Also to identify patient factors and other variables associated with these decisions.
Retrospective uncontrolled observational study carried out through record review.
A single skilled-level teaching NH and its affiliated university hospital.
All of the 350 individuals who resided at the NH during a 2-year period.
Code status decisions were routinely sought through discussion involving primary care physician/social worker teams and residents or surrogates of demented patients. Choices were made for 80% of the NH residents, most (73%) by surrogates and most (80%) for do-not-resuscitate (DNR) orders, usually within 10 weeks of NH admission. Neither short-term measures of NH care intensity nor hospital use changed after a DNR decision. Most (80%) hospital transfer records included code status documentation. At the NH, both the likelihood of decisions and their directions were associated with involvement by specific physician/social worker teams. Additionally, a dementia diagnosis, white race, and older age were associated with a nursing home DNR decision. At the hospital, a DNR order was associated with white race, the presence of nursing home DNR documentation in the transfer records, hospital attending care by certain NH physicians, and a terminal hospital stay. Hospital inpatient medical and surgical therapy use, except for intensive care procedures, was similar for DNR and non-DNR inpatients. Residents with DNR orders had a higher mortality rate, yet most survived at least 1 year after the order. In the short term, a DNR order had no impact on measured health care resource consumption, but, for those in the final months of life, in-patient hospital use was less for the DNR group, and most of these died at the nursing home.
Prehospital code status decisions can be made effectively within the NH setting. Outside of medical intensive care, DNR orders have no impact on NH and hospital care intensity in the short term. In the final 6 months of life, however, hospital use is less for the DNR subgroup.
探讨在养老院（NH）环境中进行院外急救状态讨论的临床实用性以及所做决策的医疗保健结果。同时确定与这些决策相关的患者因素和其他变量。
通过记录审查进行回顾性非对照观察性研究。
一家单一技能水平的教学型养老院及其附属大学医院。
在两年期间居住在该养老院的所有350名个体。
通常通过初级保健医生/社会工作者团队与痴呆患者的居民或代理人进行讨论来寻求急救状态决策。为80%的养老院居民做出了选择，大多数（73%）由代理人做出，大多数（80%）选择了不进行心肺复苏（DNR）医嘱，通常在入住养老院后10周内做出。做出DNR决策后，养老院护理强度的短期指标和医院使用情况均未改变。大多数（80%）医院转诊记录包含急救状态文件。在养老院，决策的可能性及其方向均与特定医生/社会工作者团队的参与有关。此外，痴呆诊断、白人种族和高龄与养老院DNR决策有关。在医院，DNR医嘱与白人种族、转诊记录中存在养老院DNR文件、某些养老院医生的医院主治护理以及医院末期住院有关。除重症监护程序外，DNR和非DNR住院患者的医院内科和外科治疗使用情况相似。有DNR医嘱的居民死亡率较高，但大多数在医嘱下达后至少存活了1年。短期内，DNR医嘱对所测量的医疗保健资源消耗没有影响，但对于生命最后几个月的患者，DNR组的住院使用较少，且其中大多数在养老院死亡。
在养老院环境中可以有效地做出院外急救状态决策。在医疗重症监护之外，短期内DNR医嘱对养老院和医院护理强度没有影响。然而，在生命的最后6个月，DNR亚组的医院使用较少。
