Effect of Timing of Do-Not-Resuscitate Orders on the Clinical Outcome of Critically Ill Patients

백문성,Younsuck Koh,Sang-Bum Hong,Chae-Man Lim,Jin Won Huh 대한중환자의학회 2016 Acute and Critical Care Vol.31 No.3

Background: Many physicians hesitate to discuss do-not-resuscitate (DNR) orders with patients or family members in critical situations. In the intensive care unit (ICU), delayed DNR decisions could cause unintentional cardiopulmonary resuscitation, patient distress, and substantial cost. We investigated whether the timing of DNR designation affects patient outcome in the medical ICU. Methods: We enrolled retrospective patients with written DNR orders in a medical ICU (13 bed) from June 1, 2014 to May 31, 2015. The patients were divided into two groups: early DNR patients for whom DNR orders were implemented within 48 h of ICU admission, and late DNR patients for whom DNR orders were implemented more than 48 h after ICU admission. Results: Herein, 354 patients were admitted to the medical ICU and among them, 80 (22.6%) patients had requested DNR orders. Of these patients, 37 (46.3%) had designated DNR orders within 48 hours of ICU admission and 43 (53.7%) patients had designated DNR orders more than 48 hours after ICU admission. Compared with early DNR patients, late DNR patients tended to withhold or withdraw life-sustaining management (18.9% vs. 37.2%, p = 0.072). DNR consent forms were signed by family members instead of the patients. Septic shock was the most common cause of medical ICU admission in both the early and late DNR patients (54.1% vs. 37.2%, p = 0.131). There was no difference in in-hospital mortality (83.8% vs. 81.4%, p = 0.779). Late DNR patients had longer ICU stays than early DNR patients (7.4 ± 8.1 vs. 19.7 ± 19.2, p < 0.001). Conclusions: Clinical outcomes are not influenced by the time of DNR designation in the medical ICU. The late DNR group is associated with a longer length of ICU stay and a tendency of withholding or withdrawing life-sustaining treatment. However, further studies are needed to clarify the guideline for end-of-life care in critically ill patients.

중환자실 간호사가 경험한 심폐소생술금지 환자의 윤리적 문제에 대한 윤리적 의사결정

장재인 한국의료윤리학회 2019 한국의료윤리학회지 Vol.22 No.3

This article reports on a study that was carried out to document and understand the experiences that nurses in intensive care units in South Korea have when dealing with Do-not-resuscitate (DNR) orders. The participants in the study were 13 intensive care units nurses, each of whom has at least four years of relevant experience with ethical decision-making concerning DNR orders. Data analysis was based on the content analysis method used in qualitative research. The study found that the ethical values of nurses concerning the treatment and death of patients with DNR orders are not fixed but rather change according to the patient’s situation. This result indicates that it is necessary to provide clearer guidelines for decisions regarding patient care in the context of DNR orders. In addition, further education or training programs concerning DNR orders should be provided to nurses working in intensive care units in South Korea. 중환자실에서의 심폐소생술금지 환자 간호와 관련된 윤리적 문제에 대한 윤리적 의사결정은 간호사의 윤리적 가치에 따른 것으로 생애말기환자 간호의 질과 관련되어있다. 따라서 본 연구는 중환자실간호사가 심폐소생술금지 환자 간호 시 경험한 윤리적 문제에 대한 윤리적 의사결정에 대한 경험을 심층적으로 이해하고 현상을 기술하기 위한 질적연구이다. 연구대상자는 심폐소생술금지 환자를 돌본 경험이 있고, 윤리적 문제를 경험한 임상경력 4년 이상의 종합병원 중환자실간호사 13명이다. 자료수집은 반구조화된 질문을 이용한 개별면담을 통하여 진행하였다. 연구 참여자 보호를 위하여 연구 참여 전연구목적과 연구방법에 대해 충분히 설명한 후 연구동의서를 얻고 진행하였다. 인터뷰 시 녹음된 내용은 연구목적으로만 사용되며 참여자가 원할 시에는 언제든지 연구참여 철회가 가능함을 설명하였다. 자료분석은 질적연구의 내용분석방법을 이용하였고 도출된 연구결과의 중심범주는 ‘너무 가벼운 죽음의 무게’, ‘존중받지 못하는 생명’의 2개 범주이다. 윤리적 의사결정에서의 가치는 ‘죽음에 대한 자기결정권’, ‘생명존중’, ‘존엄한 죽음’, ‘신념과 사명감’의 4개 가치로 나타났고 의사결정 시 모습은 ‘환자와 함께 하는 동반자’, ‘가족의 든든한 지원자’, ‘관계 속의 협력자’의 모습으로 나타났다. 의사결정에서 간호사들이 보여준 행동은 ‘환자편이 되어줌’, ‘가족의 버팀목이 되어줌’, ‘가치와는 다른 간호를 수행함’으로나타났다. 본 연구를 통해 중환자실간호사들은 심폐소생술금지 환자에 대한 치료와 죽음에 대한 윤리적 가치가 확고하게 정립되어 있지 못하고 환자의 상황에 따라 변화하고 있음을 알 수 있었다. 임상현장에서 경험하는 간호사들의 윤리적 문제에 대한 의사결정은 객관적인 관점에서 합의된 병원차원에서의 의사결정이 이루어져야 할 것이며, 심폐소생술금지 결정에 대한 기준과 치료범위에 대한 명확한 기준이 제시되어야 하는 것으로 나타났다. 따라서 실무에서 경험하는 실제적인 윤리적 문제를 사례로 병원 규모별, 간호등급별 체계화된 논의와 교육이 시행되어야 할 것이다.

한 내과계 중환자실에서 사망한 환자들의 심폐소생술 거절 현황

이광하,장항제,홍상범,임채만,고윤석 대한중환자의학회 2008 Acute and Critical Care Vol.23 No.2

Background: Do-not-resuscitate (DNR) in the event of a cardiac arrest is the most common and important discussion between a patient`s family and physicians among the end-of-life decision-making process. To observe the performance of a DNR order in critically ill patients, we analyzed the incidence of DNR orders, the changes in therapeutic levels after DNR orders, and the cases of violated DNR codes in patients who had died in a Korean medical intensive care unit (ICU) between 1 January 2006 and 30 June 2006. Methods: The charts of patients who had died in the medical ICU were retrospectively reviewed. Results: One hundred two patients were enrolled. The ICU and hospital lengths of stay of the patients were 12.4 ± 14.0 and 23.2 ± 21.1 days, respectively. Hematologic malignancy (24.5%) accounted for the most common premorbid diagnosis before ICU admission. Seventy-five patients (73.5%) had DNR orders. The DNR order was suggested by the physician in 96% of the patients. There was no significant difference in the clinical parameters and the performance of a DNR order. Eighty-four percent of the patients with a DNR order had received the order within 3 days death. The withholding of additional therapy or withdrawing of current therapy occurred in 57.3% of the patients. The DNR order was violated in 9 cases (12%). Conclusions: DNR orders are well-accepted by the patient`s family in the ICU. However, DNR orders are initiated when patient death is imminent.

심폐소생술 시행 시 구령집단과 비구령집단 간의 심폐소생술 정확도 비교

박상섭(Park, Sang-Sub),안주영(An, Ju-Yeong) 한국산학기술학회 2011 한국산학기술학회논문지 Vol.12 No.6

본 연구는 심폐소생술 시행 시 구령집단과 비구령집단 간의 심폐소생술 정확도 비교를 통하여 심폐소생술 시행에 효율성과 정확성을 높이고자 한다. 본 연구는 G도에 소재 대학생 62명(비구령집단 31명, 구령집단 31명)을 편 의추출 하였으며, 조사기간은 2010년 10월 7일부터 10월 21일까지 이루어졌다. 분석방법은 SPSS WIN(Version 12.0) 프로그램을 이용하여 분석하였다. 연구결과 심폐소생술 시행 시 비구령집단이 구령집단보다 여러 영역에서 인공호흡 과 가슴압박에 대한 심폐소생술의 정확도가 높게 나타났다. 이를 바탕으로 차후 심폐소생술 교육과 술기를 수행함에 있어서 비구령방법을 적용해 볼 필요가 있다. 그리고 응급상황에서 구령방법과 비구령방밥 간의 효과성에 대한 지속적 연구도 필요하다. The purpose of this study is to increase efficiency and accuracy in operation of CPR(Cardiopulmonary Resuscitation) through comparing accuracy in CPR between group with verbal order and group with non-verbal order given carrying out CPR. This study performed convenience sampling targeting 62 students(31 people for group with non-verbal order, 31 people for group with verbal order) at university where is located in G Province. Survey period was carried out from October 7, 2010 to October 21. Analytical method was made by using SPSS WIN(Version 12.0). As a result of research, the group with non-verbal order was indicated to be higher in accuracy of CPR on artificial respiration and chest compression in several spheres than the group with verbal order. Based on this, the non-verbal order method needs to try to be applied to performing education and skills of CPR in the future. And, even a continuous research is needed on effectiveness between verbal order method and non-verbal order method in an emergency situation.

응급의료에서 소생술에 관한 결정 : 유보, 중단을 중심으로

김아진 이화여자대학교 생명의료법연구소 2014 생명윤리정책연구 Vol.8 No.2

심정지가 발생한 환자들에게 특별한 예외가 없다면 심폐소생술은 즉각적으로 시행되어 져야 한다. 그러나 소생술이 궁극적으로 심장기능의 회복에 도움을 주지 않고, 당사자가 소생술을 원하지 않았던 것이 명백하다는 이 2가지가 모두 만족된다면 소생술의 유보나 중단은 정당화 될 수 있다. 국내의 현실적 여건과 응급실의 상황들을 고려할 때 이러한 필수적 요건들이 충분한 근거에 의해서 만족되기 어렵다. 이에 저자는 심정지가 발생한 후 병원 전 단계와 병원단계에서 심폐소생술을 유보하거나 중단할 수 있는 시점들을 지정하였으며, 이때에 만족시켜야 하는 요건들을 알아보았다. 병원 전 단계 심정지에서는 응급구조사가 심폐소생술을 시행하기 때문에 유보나 중단에 대하여 의학적 측면에 근거한 의료지도가 필수적이다. 병원 단계 중 응급실의 초기 단계에서는 생명의 이익에 근거한 의학적 판단이 주를 이룬다. 그러나 심정지 후 치료까지를 포함한 넓은 범위의 심폐소생술의 과정에서는 후반부에 이를수록 의학적 판단 이외에도 가치 판단적 요인들이 포함되어야 한다. 이를 위하여“심정지시 응급실에서의 의사결정”이 필요하다. 심폐소생술의 유보, 중단을 위해서는 단계에 따라 충족시켜야하는 요건들이 달라질 수 있으며, 환자 이익의 측면에서 이를 정당화 시키는 절차가 필요하다. CPR should be performed immediately after cardiac arrest without the special exceptions. If CPR don’t help the recovery of heart function and if the patient don't want CPR in advance, withholding and withdrawal of CPR can be justified. Domestic practical conditions and environments of EMS prevent two requirements from being satisfied. We showed the entire CPR flow, the possible steps and requirements not to resuscitate. Physician’s medical directions are necessary in prehospital phase. In early hospital phase, to withdraw CPR would be on the physician’s judgement for the patient’s life interest as well. Physician should consider the patient’s value and non-medical factors in later CPR phase. There should be the different requirements to each step for withholding and withdrawal of CPR. The institution’s modeling of decision making CPR can be complementary to the present system.

병원내 심폐소생술 결과를 예측할 수 있는 지표

오범진,황성오,홍은석,임종천,김선만,이진웅,이강현,임경수 대한응급의학회 1998 대한응급의학회지 Vol.9 No.1

Background and purpose: The purpose of this study is to compare two clinical predictive rules, the pre-arrest-morbidity(PAM) index and the prognosis-after-resuscitation(PAR) score, which predict failure to survive following in-hospital cardiopulmonary resuscitation(CPR). Method: The study population consisted of 162 consecutive adult patients who underwent CPR at Wonju Christian Hospital over a year period. The PAM index and PAR score were calculated from the most recent data available for each variable prior to cardiac arrest. Each predictive tool was compared between the group of discharge alive and the group of in-hospital mortality. Performance of the predictive scores was also compared by receiver-operating characteristic(ROC) curves where appropriate. Results: PAM index of study population was 4.39±2.69 and PAR score was 2.99±3.36. PAM index in the group of discharge alive was 1.87±2.79, and PAM index in the group of in-hospital mortality was 4.51±2.62. PAR score in the group of discharge alive was 0.75±1.75, and PAR score in the group of in-hospital mortality was 3.1±3.4. The PAM index identified 15 patients with a score>8, while the PAR score identified 39 patients with a score>4, none of whom survived. The sensitivity of the PAR score for the prediction of failure to survive was 25%, while that of the PAM index was 10%, neither index incorrectly identified a patient as a non-survivor who eventually survived. Both of predictive methods were not significantly different in the ROC curve. Conclusion: Although further comfirmation is necessary, PAM index and PAR score may provide useful prognostic information to physicians and patients involved with decisions about do-not-resuscitate orders.

"실폐소생술포기(DNR)"에 대한 요청서 및 지시서 개발

한성숙(Han Sung Suk),김중호(Kim Joong Ho),문인성(Moon In Sung),용진선(Yong Jin Sun) 한국생명윤리학회 2005 생명윤리 Vol.6 No.1

The subjects of the study are First, to accumulate DNR related guideline and DNR request and order, questionnaires were sent to 70 randomly selected university hospitals and general hospitals, and the data were collected between July and September 2004. Second, after the draft of DNR request and order was developed, the first professional group (total 12 people) to seek advise regarding the draft was formed including four doctors, three head nurses, two ministers, two philosophers, and one legal professional. The second professional group (5 people) included four doctors and a legal professional who presented significant opinions in the first advisory meeting, and they discussed the revised draft during the second advice. In this study, Delphi technique was used to develop DNR requests and order. The instrument was the draft of DNR request and order form developed by researchers for our hospital based on DNR request and order collected from 9 institutions at home and materials from abroad for the development of DNR instructions and requests. For the final revision of DNR request and order form, we've decided to prepare some space to write down the diagnosis, the progress of treatment, and the prognosis of patients on the back of the form, and us e it for explaining and seeking the consent in compliance with the regulation of the hospital ethics committee. Also we've decided to call the form "DNR request and order form". Regarding the suggestion from the hospital ethics committee, the legal interpretation is needed advised; the second suggestion from a legal professional could be an alternative. This "DNR request form" will be evaluated after one year of trial in our hospital from March 1 2005. Furthermore, for the proper use of this form, we are planning to publicize to develop and use "DNR guides". I suggest developing the forms of living wills or advance directives, for they are of use in case that patient can't make his own decision due to any abrupt accident.

심폐소생술 금지(Do-Not-Resuscitate) 주 결정 가족원의 사별 후경험

김명희(Kim, Myung Hee),강은희(Kang, Eun Hee) 한국재활간호학회 2011 재활간호학회지 Vol.14 No.2

Purpose: The purpose of this study was to explore the experiences of bereavement for main family members who had made and followed DNR decision for their family members. Method: This qualitative study was based on a grounded theory, and used in-depth interview techniques with the bereaved 10 main family members who had been treated and died under DNR order. Results: The causal condition of the family member was ‘eleasing’ and the main consequent phenomenon were ‘laming self and ruminating’ The contextual condition was ‘he memory of the deceased’ The action/reaction strategy was ‘urifying’ The intervening condition was ‘upporting system’ and the consequence was ‘cceptance’ The experience after bereavement of the family member on DNR decision were rational processes that purified themselves and healed the guilt feeling about the decision from reflective assessment and response about DNR decision. Based on this results, the substantive theory ‘eflective self healing’ was derived. Conclusion: The main family members in following DNR decision are more likely to have unhealthy emotional condition than others in normal bereavement process. But they overcame the grief of bereavement through reflective self healing process.

심폐소생술 시 구조자의 간소화된 구령방법과 연속된 구령방법 간의 가슴압박 질 효과

백홍석(Hong-Seok Baek),박상섭(Sang-Sub Park) 한국콘텐츠학회 2013 한국콘텐츠학회논문지 Vol.13 No.4

본 연구는 심폐소생술 시 음성측정기를 활용하여 구조자의 간소화된 구령방법과 연속된 구령방법과의 가슴압박 질 비교를 통해 심폐소생술의 효율성을 높이고자 한다. 대상자는 C도 소재 응급구조과 재학생으로 심폐소생술 15주 교육과정을 이수한 89명(실험군 45명, 대조군 44명)을 무작위추출 하여 시행하였다. 집단 구분은 간소화된 구령집단을 실험군, 연속적 구령집단을 대조군으로 하였다. 실험측정 기간은 1차(2011년 11월 10일, 11월 28일)와 2차(2012년 9월3일-9월4일)로 진행하였다. 분석은 SPSS WIN 12.0 program을 사용하였다. 연구결과 적절한 가슴압박(회, %)은 실험군(102.86회, 67.79%)이 대조군(85.31회, 55.84%) 보다 가슴압박 질 효과가 높았다(p<.05). 반면, 약한 가슴압박(회) 시행은 실험군(35.54회) 보다 대조군(61.13회)이 높았다. 성별에 있어서는 실험군의 남자가, 체중에 있어서는 실험군의 60kg이상이 적절한 가슴압박을 보였다(p<.05). The purpose of this study is to increase efficiency of CPR through comparing the chest-compression quality between rescuers simplified verbal order method and the continued verbal order method by utilizing voice meter during CPR. Subjects were 89 people(45 people for the experimental group, 44 people for the control group) who completed the 15-week CPR curriculum as undergraduates for the department of Emergency Medical Technology in C Province and were carried out by being randomly extracted. The group division was set for the experimental group as the group with the simplified verbal order and for the control group as the group with the continued verbal order. The period of measurement was progressed primarily(November 10, November 28, 2011) and secondarily(September 3-September 4, 2012). An analysis was used SPSS WIN 12.0 program. As a result of research, as for the implementation of appropriate chest compression(time, %), the quality was higher(p<.05) in the experimental group(102.86 times, 67.79%) than the control group(85.31 times, 55.84%). As a result of research, the chest compression(time, %) in the experimental group(102.86 times, 67.79%) had the higher effect of chest compression quality(p<.05) than the control group(85.31 times, 55.84%). On the other hand, the operation of weak chest compression(time) was higher in control group(61.13 times) than experimental group(35.54 times). The proper chest compression was shown(p<.05) in men of the experimental group as for gender and in over 60kg of the experimental group as for weight.

Taiwanese Parents’ Experience of Making a “Do Not Resuscitate” Decision for Their Child in Pediatric Intensive Care Unit

Shu-Mei Liu,Hung-Ru Lin,Frank L. Lu,Tzu-Ying Lee 한국간호과학회 2014 Asian Nursing Research Vol.8 No.1

Purpose: The purpose of this project was to explore the parental experience of making a “do not resuscitate” (DNR) decision for their child who is or was cared for in a pediatric intensive care unit in Taiwan. Methods: A descriptive qualitative study was conducted following parental signing of a standard hospital DNR form on behalf of their critically ill child. Sixteen Taiwanese parents of 11 children aged 1 month to 18 years were interviewed. Interviews were recorded, transcribed, analyzed and sorted into themes by the sole interviewer plus other researchers. Results: Three major themes were identified: (a) “convincing points to sign”, (b) “feelings immediately after signing”, and (c) “postsigning relief or regret”. Feelings following signing the DNR form were mixed and included “frustration”, “guilt”, and “conflicting hope”. Parents adjusted their attitudes to thoughts such as “I have done my best,” and “the child’s life is beyond my control.” Some parents whose child had died before the time of the interview expressed among other things “regret not having enough time to be with and talk to my child”. Conclusion: Open family visiting hours plus staff sensitivity and communication skills training are needed. To help parents with this difficult signing process, nurses and other professionals in the pediatric intensive care unit need education on initiating the conversation, guiding the parents in expressing their fears, and providing continuing support to parents and children throughout the child’s end of life process.