Koch K A, Rodeffer H D, Wears R L
University of Florida Health Science Center/Jacksonville.
Crit Care Med. 1994 Feb;22(2):233-43. doi: 10.1097/00003246-199402000-00013.
To empirically describe changes in terminal care management behavior over time with the advent of natural death acts and public dialogue and institutional policy regarding terminal care.
Retrospective analysis of medical decision-making and outcome was performed in a cohort of 237 intensive care unit (ICU) patients who received a do-not-resuscitate decision.
Medical ICU in a tertiary care center.
The cohort of 237 consecutive patients who received a terminal care decision in the ICU, i.e., a do-not-resuscitate decision with or without additional limitation of care, represented 9.3% of 2,185 patients admitted to the ICU over a 4-yr period. Brain-dead patients were excluded from the cohort.
Implementation of hospital-wide policies on do-not-resuscitate decisions and discontinuation of life-prolonging procedures in 1986.
A change in frequency and nature of terminal care decisions occurred. By 1988, do-not-resuscitate decisions occurred twice as often as in 1984 (p = .016) compared with ICU deaths. Formal terminal wean decisions, i.e., additional limitation or withdrawal of care, occurred more frequently after 1985 (p = .027). The hospital mortality rate for the do-not-resuscitate cohort was 96.4% (226/237). The diagnosis of cardiac arrest was correlated with subsequent terminal care decisions (p = .0005, r2 = .08). Age of >56 yrs was increasingly correlated with probability of a terminal care decision (p < .0001, r2 = .05). White women received withdrawal of care most frequently, followed by white men, African American men, and African American women. Outcomes analysis indicated that after a do-not-resuscitate decision, most nonsurvivors died within 48 hrs. Eleven patients without additional limitation or withdrawal of care survived to hospital discharge (11/237 [4.6%]). No patient survived a terminal wean.
There is now an increasing probability that impending death will be acknowledged by a formal terminal care decision. Such decisions may become even more frequent with the dialogue generated by the Patient Self Determination Act and the advent of decisions based on physiologic futility.
通过自然死亡法案的出现以及关于临终护理的公众对话和机构政策，实证描述随着时间推移临终护理管理行为的变化。
对237名接受了不进行心肺复苏决定的重症监护病房（ICU）患者进行队列研究，回顾分析其医疗决策和结果。
一家三级医疗中心的医疗ICU。
该队列包括237名在ICU连续接受临终护理决定的患者，即接受了有或没有额外护理限制的不进行心肺复苏决定，占4年期间入住ICU的2185名患者的9.3%。脑死亡患者被排除在该队列之外。
1986年实施全院范围的不进行心肺复苏决定政策以及停止延长生命的程序。
临终护理决定的频率和性质发生了变化。到1988年，与ICU死亡人数相比，不进行心肺复苏决定的发生率是1984年的两倍（p = 0.016）。正式的临终撤机决定，即额外的护理限制或护理撤除，在1985年之后更频繁地出现（p = 0.027）。不进行心肺复苏队列的医院死亡率为96.4%（226/237）。心脏骤停的诊断与随后的临终护理决定相关（p = 0.0005，r2 = 0.08）。年龄大于56岁与临终护理决定的可能性越来越相关（p < 0.0001，r2 = 0.05）。白人女性接受护理撤除的频率最高，其次是白人男性、非裔美国男性和非裔美国女性。结果分析表明，在做出不进行心肺复苏决定后，大多数非幸存者在48小时内死亡。11名没有额外护理限制或护理撤除的患者存活至出院（11/237 [4.6%]）。没有患者在临终撤机后存活。
现在通过正式的临终护理决定承认即将到来的死亡的可能性越来越大。随着《患者自主决定法案》引发的对话以及基于生理无意义的决定的出现，此类决定可能会更加频繁。
