Increased risk of death in patients with do-not-resuscitate orders
Increased risk of death in patients with do-not-resuscitate orders
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DOI：
10.1097/00005650-199908000-00003
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发表时间：
1999-08-01
期刊：
影响因子：
3
通讯作者：
Rosenthal, GE
中科院分区：
文献类型：
--
作者：
Shepardson, LB;Youngner, SJ;Rosenthal, GE
背景。尽管研究表明接受不复苏 (DNR) 指令的患者死亡率较高，但大多数研究并未考虑与使用 DNR 指令相关的混杂因素和/或与死亡风险相关的因素。 目的。确定 DNR 指令的使用与院内死亡率之间的关系，调整疾病的严重程度和其他协变量。设计。回顾性队列研究。患者。 1991 年至 1994 年间，30 家医院连续有 13,337 例中风入院。为了减少选择偏差，我们制定了反映 DNR 订单可能性的倾向评分。评分基于与 DNR 指令使用独立相关的九个人口统计和临床变量。然后使用逻辑回归、倾向评分调整、疾病严重程度和其他因素来确定接受 DNR 指令的患者的死亡几率。 结果。 22% (n = 2,898) 的患者使用了 DNR 指令。在检查住院期间任何时间写下的 DNR 医嘱的分析中，有 DNR 医嘱的患者未经调整的院内死亡率高于没有医嘱的患者（40% vs. 2%，P < 0.001）；调整后的死亡几率为 33.9（95% CI，27.4-42.0）。在仅考虑前 2 天（OR 3.7；95% CI，3.2-4.4）或第一天（OR 2.4；95% CI，2.0-2.9）期间写下的订单的分析中，调整后的死亡几率仍然较高。在分层分析中，倾向评分较低的患者的调整后死亡几率往往较高。结论。在调整倾向评分和其他协变量后，接受 DNR 指令的患者的死亡风险显着较高。尽管风险增加可能反映了患者对较少重症监护或未测量的预后因素的偏好，但当前的研究结果强调需要对接受 DNR 指令的患者的护理质量和适当性进行更直接的评估。
BACKGROUND. Whereas studies have shown higher mortality rates in patients with do-not-resuscitate (DNR) orders, most have not accounted for confounding factors related to the use of DNR orders and/or factors related to the risk of death.OBJECTIVE. TO determine the relationship between the use of DNR orders and in-hospital mortality, adjusting for severity of illness and other covariates.DESIGN. Retrospective cohort study.PATIENTs. There were 13,337 consecutive stroke admissions to 30 hospitals in 1991 to 1994.MEASURES. TO decrease selection bias, propensity scores reflecting the likelihood of a DNR order were developed. Scores were based on nine demographic and clinical variables independently related to use of DNR orders. The odds of death in patients with DNR orders were then determined using logistic regression, adjustment for propensity scores, severity of illness, and other factors.RESULTS. DNR orders were used in 22% (n 2,898) of patients. In analyses examining DNR orders written at any time during hospitalization, unadjusted in-hospital mortality rates were higher in patients with DNR orders than in patients without orders (40% vs. 2%, P < 0.001); the adjusted odds of death was 33.9 (95% CI, 27.4-42.0). The adjusted odds of death remained higher in analyses that only considered orders written during the first 2 days (OR 3.7; 95% CI, 3.2-4.4) or the first day (OR 2.4; 95% CI, 2.0-2.9). In stratified analyses, adjusted odds of death tended to be higher in patients with lower propensity scores.CONCLUSION. The risk of death was substantially higher in patients with DNR orders after adjusting for propensity scores and other covariates. Whereas the increased risk may reflect patient preferences for less intensive care or unmeasured prognostic factors, the current findings highlight the need for more direct evaluations of the quality and appropriateness of care of patients with DNR orders.