Attempting resuscitation in nursing homes: Policy considerations
Attempting resuscitation in nursing homes: Policy considerations
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DOI：
10.1111/j.1532-5415.1999.tb05211.x
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发表时间：
1999-10-01
影响因子：
6.3
通讯作者：
Harper, GM
中科院分区：
文献类型：
--
作者：
Finucane, TE;Harper, GM
Thomas E. Finucane 医学博士和 G. Michael Harper 医学博士指出，美国 A 疗养院每年约有 372,000 人死亡，占全国死亡人数的六分之一。“当一名居民被发现失去脉搏时，临床医生通常会面临一个难题：要么 (1) 医疗机构发生潜在致命的紧急情况，要么 (2) 晚期进展性疾病或多种疾病的组合最终导致患者在其住所死亡。然后所需的决定在老年病学中很常见：要么停止潜在的维持生命的治疗，要么启动几乎没有成功机会的侵入性干预。在这种情况下，尝试进行心肺复苏（ACPR）干预。复苏，“使明显死亡的人恢复生命或意识”2 在这里很少见。因此，我们使用“尝试心肺复苏”一词。美国的决策通常遵循逐步的方法，我们将其称为标准范式，首先强调患者自主的价值，然后是对生命的尊重。首先，如果你想知道为一个人做什么，你应该问他或她。其次，如果患者缺乏回答能力，请寻求预先指示。第三，如果患者缺乏能力和指令，则确定合法的替代决策者。最后，如果尚未做出决定，请采取行动保护生命。人们对这一范式提出了一些挑战。如果治疗不太可能使患者受益怎么办？如果治疗非常昂贵怎么办？如果患者不想帮助做出决定怎么办？在本文中，我们研究了在美国疗养院必须做出有关 ACPR 的决定时实际发生的情况。主要基于标准范式的政策是否指导临床实践？结果如何？除了尊重自主权和尊重生命之外，我们还列举了一些我们认为可能会影响实践的附带考虑因素。我们注意到，当疗养院通过在同一场所增加高危度降级单位进行医疗时，弱势长期护理居民面临特殊风险。我们的结论是，政策应该改变。
Thomas E. Finucane, MD, and G. Michael Harper, MD bout 372,000 people die in American nursing homes A annually, accounting for one-sixth of all deaths nationally.'When a resident is found pulseless, clinicians commonly face a conundrum: either (1) a potentially fatal emergency is occurring in a medical facility, or (2) an advanced progressive illness, or combination of illnesses, has culminated in death at the person's residence. The decision then required is common in geriatrics: either withhold potentially life-sustaining treatment or initiate an invasive intervention with little chance of success. In this case, the intervention is attempted cardiopulmonary resuscitation (ACPR). Resuscitation," restoration to life or consciousness of one apparently dead," 2 is rare here. Accordingly, we use the phrase attempted cardiopulmonary resuscitation. Decision-making in the United States generally follows a step-wise approach, which we will refer to as the Standard Paradigm, emphasizing primarily the value of patient autonomy, then a reverence for life. First, if you want to know what to do for a person, you should ask him or her. Second, if the patient lacks capacity to answer, seek advance directives. Third, if the patient lacks both capacity and directives, identify legitimate substitute decision-makers. Finally, if no decision has been made, act to preserve life. Several challenges have been made to this paradigm. What if a treatment is very unlikely to benefit the~ atient?~ What if it is very e~ pensive?~ What if the patient does not want to help make the decision?'In this paper we examine what actually happens when decisions about ACPR must be made in American nursing homes. Do policies, based largely on the Standard Paradigm, guide bedside practice? What are the outcomes? We enumerate collateral considerations, beyond respect for autonomy and reverence for life, that we feel may affect practice. We note special risk to vulnerable long-term care residents when nursing homes are medicalized by the addition of high acuity stepdown units on the same premises. We conclude that it is the policies that should change.