Kernerman P, Cook D J, Griffith L E
Department of Critical Care, University of Toronto, Ontario, Canada.
J Crit Care. 1997 Dec;12(4):155-60. doi: 10.1016/s0883-9441(97)90026-5.
The purpose of this article was to determine the extent to which patients at high risk of hospital death who undergo cardiopulmonary resuscitation (CPR) have previously had their life support preferences addressed and documented.
We conducted a retrospective chart review of all patients older than 18 years of age hospitalized for more than 24 hours who sustained a cardiac arrest with attempted CPR at our tertiary care university teaching hospital during 1994 (n = 71). We searched all hospital charts specifying ICD-9 codes: Cardiac arrest, ventricular fibrillation, ventricular tachycardia, asystole, electromechanical dissociation, defibrillation, or CPR. Patients were selected if (1) they had a true cardiac arrest (abrupt cessation of spontaneous circulation) and (2) had attempted CPR or defibrillation. Patients were classified as "high risk" if they satisfied at least one of the following: modified prearrest morbidity index > or = 7, moderate/severe dementia, day 1 APACHE II score > 24 or > or = 4 dysfunctional organ systems.
We searched 147 charts; of 71 patients meeting inclusion criteria, 53 were high risk. Of patients at high risk of sustaining a cardiopulmonary arrest during the index hospital admission, 3 (6%) had preferences addressed within the first 24 hours of hospitalization, 7 (13%) had delayed discussion of preferences before arrest, 23 (43%) had preferences addressed post arrest, and 20 (38%) had no documented discussions. Of the 23 high-risk patients initially surviving cardiac arrest, all were subsequently given "do not resuscitate" orders. Univariate analysis of factors associated with life-support discussion before cardiac arrest were previous cardiac arrest (OR, 5.9) and APACHE II score > 24 (OR, 1.1), although neither reached statistical significance. None of the 32 patients with a modified PAM index > or = 7 (32 of 71) survived hospitalization. Only 3 patients survived to hospital discharge.
Early communication regarding life-support preferences is important in high-risk patients so that inappropriate or unwanted treatment is not implemented. Given that optimal care includes addressing and documenting life-support preferences in high-risk patients early in their hospitalization, this standard was infrequently met.
本文旨在确定接受心肺复苏（CPR）的医院死亡高危患者，其生命支持偏好先前得到讨论并记录的程度。
我们对1994年在我们的三级医疗大学教学医院住院超过24小时、发生心脏骤停并尝试进行心肺复苏的所有18岁以上患者进行了回顾性病历审查（n = 71）。我们检索了所有指定ICD - 9编码的医院病历：心脏骤停、心室颤动、室性心动过速、心搏停止、电机械分离、除颤或心肺复苏。入选患者需满足以下条件：（1）发生真正的心脏骤停（自发循环突然停止）；（2）尝试进行心肺复苏或除颤。如果患者满足以下至少一项标准，则被分类为“高危”：改良心脏骤停前发病指数≥7、中度/重度痴呆、入院第1天急性生理与慢性健康状况评分系统（APACHE II）> 24或≥4个功能障碍器官系统。
我们检索了147份病历；在71名符合纳入标准的患者中，53名是高危患者。在本次住院期间发生心肺骤停高危的患者中，3名（6%）在住院的前24小时内讨论了偏好，7名（13%）在心脏骤停前延迟讨论了偏好，23名（43%）在心脏骤停后讨论了偏好，20名（38%）没有记录在案的讨论。在最初心脏骤停后存活的23名高危患者中，所有患者随后都收到了“不要复苏”的医嘱。对心脏骤停前与生命支持讨论相关因素的单因素分析显示，既往心脏骤停（比值比[OR]，5.9）和APACHE II评分> 24（OR，1.1），但两者均未达到统计学意义。改良PAM指数≥7的32名患者（71名患者中的32名）均未存活至出院。只有3名患者存活至出院。
对于高危患者，早期就生命支持偏好进行沟通很重要，这样可以避免实施不适当或不必要的治疗。鉴于最佳治疗包括在高危患者住院早期讨论并记录生命支持偏好，这一标准很少得到满足。
