Maksoud A, Jahnigen D W, Skibinski C I
Section of Geriatric Medicine, Cleveland Clinic Foundation, OH 44195-5001.
Arch Intern Med. 1993 May 24;153(10):1249-53.
The appropriate role of cardiopulmonary resuscitation in the hospital continues to be a topic of interest to physicians and patients alike. The use of do not resuscitate (DNR) orders reflects a growing expression of autonomy by patients to refuse medical treatment, and also a growing recognition of its futility in many circumstances by physicians. Although it has been suggested that wider use of advance directives will lead to a reduction in health care costs near the end of life, little empiric data exist to support this prediction. This study was designed to ascertain the rates of DNR orders and their associated costs.
A retrospective chart review was conducted on the hospital records of 852 of 953 hospital deaths that occurred in a referral hospital. Data were collected on resuscitation status, timing of DNR orders, participants in decision making, and physician and hospital charges.
Of the 852 records reviewed, 625 (73%) had a DNR order at the time of death. The use of DNR orders for patients who died ranged from 97% of those on an oncology service to 43% of deaths on cardiology services. One hundred seven patients (17%) had the DNR order before admission. Of 512 patients who had a new DNR order in the hospital, approval was obtained from the patient in only 19%. Patients who died with a DNR order had longer hospital stays (median, 11.0 days) compared with those who died without a DNR order (6.0 days). The time from DNR order to death was 2 days overall with 2.0 days for medical patients and 1.0 day for surgical patients. Average charges for each patient who died were $61,215 with $10,631 for those admitted with a DNR order, and $73,055 for those who had a DNR order made in hospital.
This study demonstrates high variability in the use of DNR orders between various medical and surgical services. These range from a high of 98% on an oncology service to a low of 43% on cardiology. Most patients have a DNR order at the time of death, but these typically occur late in the course of the hospital stay. Death in the hospital is costly and total hospital and professional charges are significantly lower when a patient is admitted with an established nonresuscitation order compared with those for whom a DNR is established while in the hospital. This study provides a basis against which to measure the impact of efforts such as the Patient Self-Determination Act of 1990 to increase the use of advance directives, as well as monitor their effect on health care expenditures.
心肺复苏术在医院中的恰当作用一直是医生和患者都感兴趣的话题。“不要复苏”（DNR）医嘱的使用反映出患者自主拒绝医疗治疗的意愿日益增强，同时也反映出医生在许多情况下越来越认识到其无用性。尽管有人提出更广泛地使用预立医嘱将导致临终时医疗费用的降低，但几乎没有实证数据支持这一预测。本研究旨在确定DNR医嘱的比例及其相关费用。
对一家转诊医院发生的953例医院死亡病例中的852例进行回顾性病历审查。收集了关于复苏状态、DNR医嘱下达时间、决策参与者以及医生和医院收费的数据。
在审查的852份记录中，625例（73%）在死亡时下达了DNR医嘱。死亡患者中DNR医嘱的使用率从肿瘤科室的97%到心脏科的43%不等。107例患者（17%）在入院前就有DNR医嘱。在医院下达新的DNR医嘱的512例患者中，只有19%获得了患者的批准。与未下达DNR医嘱而死亡的患者（6.0天）相比，下达DNR医嘱而死亡的患者住院时间更长（中位数为11.0天）。从下达DNR医嘱到死亡的总时间为2天，内科患者为2.0天，外科患者为1.0天。每名死亡患者的平均费用为61,215美元，入院时就有DNR医嘱的患者为10,631美元，在医院下达DNR医嘱的患者为73,055美元。
本研究表明，不同内科和外科科室在DNR医嘱的使用上存在很大差异。范围从肿瘤科室的98%到心脏科的43%不等。大多数患者在死亡时下达了DNR医嘱，但这些医嘱通常在住院后期下达。在医院死亡费用高昂，与在住院期间下达DNR医嘱的患者相比，入院时就有既定的不复苏医嘱的患者的医院总费用和专业费用显著更低。本研究为衡量诸如1990年《患者自主决定法案》等努力对增加预立医嘱使用的影响以及监测其对医疗保健支出的效果提供了一个基准。
