某區域醫院到院前心跳停止病人不施行心肺復甦術之現況分析

Analysis on Do-not-Resuscitate of Out-of-Hospital Cardiac Arrest Patients at a Regional Hospital

探討不施行心肺復甦術（DNR）在到院前心跳停止（OHCA）病人之現況。採電子病歷回溯性調查設計以2012年1月1日至2015年12月31日（共4年）期間送入急診之OHCA病人共688位進行資料分析。OHCA病人中有127人（18.5%）送入急診時即已接受死亡而無CPR，有14人（2.5%）在前次住院已簽署DNR但仍被要求急救，OHCA送入後有與家屬討論DNR的有449人（65.3%），簽署DNR者有374人（54.4%），存活病人共33人（4.8%）。而醫療團隊與家屬有討論DNR者其年齡較長（68.0±17.4歲vs. 61±18歲，p＝0.000）且CPR時間（14.6±19.5分鐘vs. 28.1±19.2分鐘，p＝0.000）亦較短。而家屬有簽署DNR者年齡較長（69.2±17.3歲vs. 61.2±17.8歲，p＝0.000）且CPR時間（1 0.8±13.5分鐘vs. 29.3±22.6分鐘 p＝0.000）亦較短存活病人中有24（佔72.7%）人意識不清*臥床需他人照顧。OHCA病人約有兩成送入時即已接受死亡並同意不急牧。因此必須宣導在宅臨終安寧照護、強化居家安寧醫師之角色。，而雖曾簽署DNR仍被要求急救者應推動预立醫療自主計畫。讓病人清醒時即先決定醫療意向。存活率低且有七成病人需依賴照護建議醫療人萯對於送入急診之OHCA病人除急救外尚須介入DNR討論使得家屬了解醫療現狀並有所選擇。

Abstract: To discuss the current condition of out-of -hospital cardiac arrest patients with Do not resuscitation. The survey is designed using medical e-records from Jan 1st 2012 to Dec 31st 2015 to analyze the information of 688 OHCA patients with CPR. Amid OHCA patients there were 127 people (18.5%) considered lifeless when brought to ER and without applying CPR; there were 14(2.5%) undergoing CPR even though the DNR was signed previously in the hospital. The cases that medical team had the DNR discussion with families of OHCA patients accounted for 449(65.3%), and 374(54.5%) of them signed the DNR while 33 patients survived (4.8%). For those patients whose families had discussed DNR with the medical team, the age is older (68.0±17.4 vs. 61±18-year old p烌0.000) and the time of CPR (14.6±19.5 vs. 28.1±19.2 mins p烌0.000) is shorter. For those patients whose families had signed the DNR, the age is older (69.2±17.3 vs. 61.2±17.8-year old p烌0.000) and the time of CPR (10.8±13.5vs. 29.3±22.6 mins p烌0.000) is shorter. Both subjects shows significant differences in statistics. 24 (72.7%) of the patients who survived were unconscious and in a coma. 18.5% of OHCA patients were considered lifeless as brought to ER and agreed on DNR. Therefore, the in-house nurse of palliative care must prevail. Patients who had signed DNR still went through CPR and thus, the advance care planning shall be promoted as the patient still had clear consciousness. The survival rate was low, and more than 70% of those who lived were in need of close care. It is suggested that apart from the CPR for OHCA patients, the medical team should have the DNR discussion with patients’ families to offer patients medical status and choices.