Alignment of Do-Not-Resuscitate Status With Patients' Likelihood of Favorable Neurological Survival After In-Hospital Cardiac Arrest.
Alignment of Do-Not-Resuscitate Status With Patients' Likelihood of Favorable Neurological Survival After In-Hospital Cardiac Arrest.
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DOI：
10.1001/jama.2015.11069
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发表时间：
2015-09-22
期刊：
影响因子：
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通讯作者：
American Heart Association’s Get With the Guidelines–Resuscitation Investigators
中科院分区：
文献类型：
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作者：
Fendler TJ;Spertus JA;Kennedy KF;Chen LM;Perman SM;Chan PS;American Heart Association’s Get With the Guidelines–Resuscitation Investigators
在患者在医院心脏骤停后，应讨论预后和未来复苏努力的偏好。评估患者在院内心脏骤停成功复苏后的不复苏（DNR）决定是否与其预期预后一致。在Get With The Guidelines®-Resuscitation中，我们在2006年4月至2012年9月期间在406家美国医院确定了26，327例院内心脏骤停后自主循环恢复（ROSC）的患者。使用先前验证的预后工具，每个患者有利的神经系统存活的可能性（即，没有严重的神经功能障碍）。在每个预后评分十分位数内DNR顺序的患者比例以及DNR状态与实际有利的神经系统生存率之间的关系进行了检查。12小时内收到拒绝抢救命令。有利的神经系统存活率。总体而言，5，944例（22.6% [95% CI：22.1%，23.1%]）患者在ROSC后12小时内接受了DNR医嘱。与未接受DNR的患者相比，该组患者年龄较大，合并症发生率较高（均P <0.05）。在预后最好的患者中（十分位数1），7.1%（95%CI：6.1%，8.1%）的患者接受了DNR命令，尽管其良好的神经系统生存率预测值为64.7%（62.8%，66.6%）。在预期预后最差的患者中（十分位数为10），36.0%（34.2%，37.8%）的患者接受了DNR治疗，尽管其良好的神经系统生存率预测值为4.0%（3.3%，4.7%）（两种趋势的P值均<0.001）。当DNR订单被重新定义为ROSC的24小时，72小时和5天内时，这种模式类似。无DNR命令的患者（30.5% [95%CI：29.9%，31.1%]）的实际良好神经系统生存率高于有DNR命令的患者（1.8% [95%CI：1.6%，2.0%]），并且在预期预后的每一个十分位数中，都可以看到DNR命令患者的生存率较低的模式。虽然住院心脏骤停后的DNR命令通常与患者有利的神经系统生存的可能性一致，但只有三分之一预后最差的患者有DNR命令。DNR命令的患者生存率低于没有DNR命令的患者，包括那些预后最好的患者。
After patients survive an in-hospital cardiac arrest, discussions should occur about prognosis and preferences for future resuscitative efforts. To assess whether patients' decisions for Do-Not-Resuscitate (DNR) orders after a successful resuscitation from in-hospital cardiac arrest are aligned with their expected prognosis. Within Get With The Guidelines®-Resuscitation, we identified 26,327 patients with return of spontaneous circulation (ROSC) after in-hospital cardiac arrest between April 2006 and September 2012 at 406 U.S. hospitals. Using a previously validated prognostic tool, each patient's likelihood of favorable neurological survival (i.e., without severe neurological disability) was calculated. The proportion of patients with DNR orders within each prognosis score decile and the association between DNR status and actual favorable neurological survival were examined. DNR orders within 12 hours of ROSC. Likelihood of favorable neurological survival. Overall, 5,944 (22.6% [95% CI: 22.1%, 23.1%]) patients had DNR orders within 12 hours of ROSC. This group was older and had higher rates of comorbidities (all P <0.05) than patients without DNR orders. Among patients with the best prognosis (decile 1), 7.1% (95% CI: 6.1%, 8.1%) had DNR orders even though their predicted rate of favorable neurological survival was 64.7% (62.8%, 66.6%). Among patients with the worst expected prognosis (decile 10), 36.0% (34.2%, 37.8%) had DNR orders even though their predicted rate for favorable neurological survival was 4.0% (3.3%, 4.7%) (P for both trends <0.001). This pattern was similar when DNR orders were re-defined as within 24 hours, 72 hours, and 5 days of ROSC. The actual rate of favorable neurological survival was higher for patients without DNR orders (30.5% [95% CI: 29.9%, 31.1%]) compared with those with DNR orders (1.8% [95% CI: 1.6%, 2.0%]), and this pattern of lower survival among patients with DNR orders was seen in every decile of expected prognosis. Although DNR orders after in-hospital cardiac arrest were generally aligned with patients' likelihood of favorable neurological survival, only one-third of patients with the worst prognosis had DNR orders. Patients with DNR orders had lower survival than those without DNR orders, including among those with the best prognosis.