“不要复苏”医嘱的使用与中风患者住院时间之间的关联。

Shepardson L B, Justice A C, Harper D L, Rosenthal G E

Cleveland VA Medical Center, Department of Epidemiology, Case Western Reserve University School of Medicine, OH, USA.

Med Care. 1998 Aug;36(8 Suppl):AS57-67. doi: 10.1097/00005650-199808001-00007.

OBJECTIVES

The study sought to describe the association between do-not-resuscitate (DNR) orders and length of hospital stay (LOS), and how the association varies according to in-hospital mortality, timing of the DNR order, and admission severity of illness.

METHODS

The authors conducted a retrospective cohort analysis involving standardized review of patients' medical records. The study was performed at 30 acute care hospitals in a large metropolitan area. The authors studied the data of 13,337 consecutive patients with a primary diagnosis of stroke discharged in 1991 through 1994.

RESULTS

Do-not-resuscitate orders were written for 22% (n = 2,898) of the sample. In all patients, mean LOS was longer in patients with DNR orders than in patients without orders (12.0 versus 9.5 days; P < 0.001). A series of Cox regression analyses were performed to adjust LOS for admission severity of illness and other covariates. In analyses of patients discharged alive (n = 12,011), LOS was similar in patients with DNR orders written on days 1 to 2 compared with patients without DNR orders. However, LOS was longer in patients with DNR orders written on days 3 to 7 (Hazard Ratio [HR], 1.59; 95% CI, 1.43-1.77) and on day 8 or later (HR, 2.72; 95% CI, 2.34-3.16). In analyses of patients who died (n = 1,326), LOS was shorter for patients with DNR orders written on days 1 and 2 (HR, 0.59; 95% CI, 0.49-0.71) than for patients without DNR orders but was longer among patients with DNR orders written on day 8 or later (HR, 2.58; 95% CI, 2.06-3.22). In analyses stratified by admission severity, the relative effect of a DNR order tended to be less in patients with higher severity.

CONCLUSIONS

The relationship between DNR orders and LOS is complex and varies according to in-hospital mortality, the timing of the DNR order, and admission severity of illness. These findings highlight the importance of explicitly accounting for such factors in studies evaluating the implications of DNR orders on the costs of hospital care.

目的

本研究旨在描述“不要复苏”（DNR）医嘱与住院时间（LOS）之间的关联，以及这种关联如何根据院内死亡率、DNR医嘱的下达时间和入院时的疾病严重程度而变化。

方法

作者进行了一项回顾性队列分析，对患者的病历进行标准化审查。该研究在一个大都市地区的30家急性护理医院进行。作者研究了1991年至1994年期间连续出院的13337例原发性诊断为中风的患者的数据。

结果

样本中有22%（n = 2898）的患者下达了DNR医嘱。在所有患者中，下达DNR医嘱的患者的平均住院时间比未下达医嘱的患者更长（12.0天对9.5天；P < 0.001）。进行了一系列Cox回归分析，以根据入院时的疾病严重程度和其他协变量对住院时间进行调整。在对存活出院患者（n = 12011）的分析中，在第1至2天下达DNR医嘱的患者与未下达DNR医嘱的患者的住院时间相似。然而，在第3至7天下达DNR医嘱的患者（风险比[HR]，1.59；95%置信区间，1.43 - 1.77）和第8天或更晚下达DNR医嘱的患者（HR，2.72；95%置信区间，2.34 - 3.16）的住院时间更长。在对死亡患者（n = 1326）的分析中，在第1天和第2天下达DNR医嘱的患者的住院时间比未下达DNR医嘱的患者短（HR，0.59；95%置信区间，0.49 - 0.71），但在第8天或更晚下达DNR医嘱的患者中住院时间更长（HR，2.58；95%置信区间，2.06 - 3.22）。在按入院严重程度分层的分析中，DNR医嘱的相对影响在病情较重的患者中往往较小。