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Use of combined do-not-resuscitate/do-not intubate orders without documentation of intubation preferences: a retrospective observational study at an academic Level 1 trauma center
Chest ( IF 9.6 ) Pub Date : 2020-07-01 , DOI: 10.1016/j.chest.2020.02.020
Jeffrey B Rubins 1
Affiliation  

BACKGROUND Combining orders for do-not-resuscitate (DNR) for cardiac arrest with do-not-intubate (DNI) orders into a DNR/DNI code status is not evidence-based practice and may violate patient autonomy and informed consent when providers discuss intubation only in the context of CPR. RESEARCH QUESTION How often do providers refer to patients with a DNR order as "DNR/DNI" without documentation of refusal of intubation for non-arrest situations? STUDY DESIGN AND METHODS Retrospective observational study of adults (18 years or older) hospitalized in a Level 1 trauma/academic hospital between July 2017 and June 2018 inclusive with DNR orders placed during hospitalization RESULTS: Of 422 hospitalized adults with DNR orders, 261 (61.9%) had code status written in progress notes as DNR/DNI. Providers' use of the term DNR/DNI in progress notes was significantly (OR 2.21 99% CI 1.12 - 4.37) more common on medical hospital services (hospitalist, family medicine, internal medicine) than on non-medical ward services (medical/surgical intensive care units, surgery, psychiatry, neurology services).Of 261 "DNR/DNI"patients, providers did not document informed refusal of intubation for non-arrest situations for 68 (26.0%) of patients. By comparison, of 161 patients where providers documented code status in progress notes as DNR alone, 69 (42.9%) did have documentation of refusal of intubation for non-arrest events. Therefore, if a DNR/DNI code status was used in a non-arrest emergency to determine whether to intubate a patient, 68 (16.1%) of 422 patients could inappropriately be denied intubation without informed refusal (or despite their informed acceptance), and 69 (16.4%) could inappropriately be intubated despite their documented refusal of intubation. INTERPRETATION Conflation of DNR and DNI into DNR/DNI does not reliably distinguish patients who refuse or accept intubation for indications other than cardiac arrest, and thus may inappropriately deny desired intubation for those who would accept it, and inappropriately impose intubation on patients who would not.

中文翻译:

在没有插管偏好文件的情况下使用联合不复苏/不插管命令:在学术 1 级创伤中心的回顾性观察研究

背景 将心脏骤停的禁止复苏 (DNR) 命令与禁止插管 (DNI) 命令合并为 DNR/DNI 代码状态不是循证实践,并且在提供者讨论插管时可能会违反患者自主权和知情同意仅在 CPR 的情况下。研究问题 提供者多久将有 DNR 命令的患者称为“DNR/DNI”而没有因非逮捕情况拒绝插管的文件?研究设计和方法 对 2017 年 7 月至 2018 年 6 月期间在 1 级创伤/学术医院住院并在住院期间下达 DNR 命令的成人(18 岁或以上)进行回顾性观察研究 结果:在 422 名有 DNR 命令的住院成人中,261 (61.9 %) 将代码状态写在进度说明中作为 DNR/DNI。供应商 与非医疗病房服务(医疗/外科重症监护)相比,在进度记录中使用术语 DNR/DNI 的情况在医疗医院服务(医院、家庭医疗、内科)中显着(OR 2.21 99% CI 1.12 - 4.37)更常见单位、外科、精神病学、神经病学服务。在 261 名“DNR/DNI”患者中,提供者没有记录 68 名 (26.0%) 患者因非逮捕情况而拒绝插管的通知。相比之下,在提供者将进展记录中的代码状态记录为仅 DNR 的 161 名患者中,69 名 (42.9%) 确实有因非逮捕事件拒绝插管的记录。因此,如果在非逮捕紧急情况下使用 DNR/DNI 代码状态来确定是否给患者插管,68 (16. 422 名患者中有 1% 的人可能在没有知情拒绝(或尽管他们知情接受)的情况下被不当拒绝插管,69 名(16.4%)可能在他们有记录拒绝插管的情况下被不当插管。解释 将 DNR 和 DNI 合并为 DNR/DNI 并不能可靠地区分因心脏骤停以外的其他指征而拒绝或接受插管的患者,因此可能不恰当地拒绝接受插管的患者所需的插管,并不恰当地对不接受插管的患者强加插管.
更新日期:2020-07-01
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