Levetown M, Pollack M M, Cuerdon T T, Ruttimann U E, Glover J J
Department of Critical Care Medicine, Children's National Medical Center, Washington, DC 20010.
JAMA. 1994 Oct 26;272(16):1271-5.
To investigate the use and implementation in pediatric intensive care units (PICUs) of three levels of restriction of medical intervention: do not resuscitate (DNR), additional limitations of medical interventions beyond DNR, and withdrawal of care.
Consecutive patients admitted between December 1989 and January 1992.
A total of 16 PICUs randomly selected to represent variability in size, teaching status, and presence or absence of a pediatric intensivist and unit coordination.
Profiles of children undergoing restrictions of medical interventions including the influence of chronic disease, the justifications for restrictions, and description of implementation practices.
All pediatric admissions undergoing restrictions (n = 119) drawn from 5415 consecutive PICU admissions.
A total of 94 (79%) of the restriction patients died during the PICU course, representing 38% of all deaths. A total of 73 restrictions (61%) resulted from acute disease, most involving the central nervous system or respiratory system. Restrictions were evenly divided between DNR (39%), additional limitations of medical intervention beyond DNR (27%), and withdrawals of medical intervention (34%). Survival decreased with increasing levels of restriction from 35% of DNR patients to 9% of patients with additional limitations and 2% of withdrawal patients. Imminent death was cited as the justification for restrictions in 70% of cases, no relational potential was cited in 22%, and excessive burden was cited in 8%.
Restrictions of medical intervention were used in all PICUs surveyed. Although severe chronic disease was common among restriction patients, acute disease was the predominant event precipitating placement of restrictions. Imminent death, not quality of life or excessive burden, was the most common justification.
调查儿科重症监护病房（PICUs）中三种医疗干预限制水平的使用及实施情况，这三种水平分别为：不进行心肺复苏（DNR）、DNR之外的额外医疗干预限制以及停止治疗。
对1989年12月至1992年1月期间收治的连续患者进行研究。
总共随机选取16个PICUs，以代表规模、教学状况以及是否有儿科重症医学专家和科室协调情况的差异。
接受医疗干预限制的儿童概况，包括慢性病的影响、限制的理由以及实施情况的描述。
从5415例连续的PICU入院患者中选取所有接受限制的儿科入院患者（n = 119）。
在PICU治疗期间，共有94例（79%）接受限制的患者死亡，占所有死亡患者的38%。共有73例限制（61%）是由急性疾病导致的，其中大多数涉及中枢神经系统或呼吸系统。限制在DNR（39%）、DNR之外的额外医疗干预限制（27%）和停止医疗干预（34%）之间平均分配。随着限制水平的提高，生存率从DNR患者的35%降至有额外限制患者的9%和停止治疗患者的2%。70%的病例将临近死亡作为限制的理由，22%未提及相关可能性，8%提及负担过重。
在所调查的所有PICUs中都使用了医疗干预限制。虽然严重慢性病在接受限制的患者中很常见，但急性疾病是导致实施限制的主要事件。临近死亡而非生活质量或负担过重是最常见的理由。
