Fins J J, Miller F G, Acres C A, Bacchetta M D, Huzzard L L, Rapkin B D
Department of Medicine, New York Hospital-Cornell Medical Center, NY, USA.
J Pain Symptom Manage. 1999 Jan;17(1):6-15. doi: 10.1016/s0885-3924(98)00109-2.
Chart review of patients who died in the hospital was used to describe the pattern of end-of-life decision-making and care for hospitalized dying patients and to propose a structured process of assessing the suitability of patients for palliative care. The setting was a large urban academic medical center, and the sample comprised 200 of 205 consecutive adult deaths during the first 4 months of 1996. The main outcome measures were identification of the patient as dying, do-not-resuscitate (DNR) orders, and comfort care plans. Charts of 72% of the patients had evidence that they were considered dying. DNR orders were in place for 77% of all the patients, and 46% had comfort care plans. Presence of a health care proxy was significantly associated with DNR orders and comfort care plans (P < 0.001). On average, comfort care plans were put in place 15 days after admission, as compared with an overall mean length of stay of 17 days. Substantial proportions of patients with comfort care plans continued to receive antibiotics (41%) and blood draws (30%). Only 13% of the patients on mechanical ventilation and 19% of those on artificial nutrition and hydration underwent withdrawal of these interventions prior to death. These findings suggest opportunities and challenges for improving practice patterns for hospitalized dying patients. We recommend several measurable objectives for evaluating end-of-life decision-making and care and propose the development of a goals of care assessment tool to guide appropriate transitions from life-sustaining treatment to comfort care and plan palliative services.
通过对在医院死亡患者的病历回顾，来描述临终决策模式以及对住院临终患者的护理情况，并提出一个评估患者是否适合接受姑息治疗的结构化流程。研究地点为一家大型城市学术医疗中心，样本包括1996年最初4个月内连续205例成人死亡病例中的200例。主要观察指标为确定患者是否处于临终状态、下达的不要复苏（DNR）医嘱以及舒适护理计划。72%的患者病历中有证据表明他们被认定为处于临终状态。所有患者中有77%下达了DNR医嘱，46%有舒适护理计划。医疗代理人的存在与DNR医嘱和舒适护理计划显著相关（P<0.001）。平均而言，舒适护理计划在入院后15天制定，而总体平均住院时长为17天。有舒适护理计划的患者中，相当一部分仍继续接受抗生素治疗（41%）和采血（30%）。在死亡前，接受机械通气的患者中只有13%、接受人工营养和补液的患者中只有19%撤掉了这些干预措施。这些发现表明，改善住院临终患者的实践模式存在机遇和挑战。我们建议制定几个可衡量的目标来评估临终决策和护理，并提议开发一种护理目标评估工具，以指导从维持生命治疗到舒适护理的适当过渡，并规划姑息治疗服务。
