重症患者医疗措施限制撤离的状况研究

A prospective study on withholding and withdrawing of life support treatment in a Chinese intensive care unit

目的调查重症患者限制或撤离医疗措施,在重症医学科(intensive care unit,ICU)的实施现状。方法前瞻性观察研究,纳入2009年6月至2011年5月,在首都医科大学附属复兴医院重症医学科住院过程中,由亲属或医生方提出"限制或撤离医疗措施",并签署《医疗措施限制撤离确定书》(下称"签署")的重症患者。搜集该患者群人口学资料,签署原因,医疗费用种类,疾病严重度及预后。并根据签署内容进行分组,分为限制治疗组(A组),撤离治疗组(B组)和仅不实施临终心肺复苏组(C组)。比较上述参数的差别。结果研究期间共有86名患者的亲属进行"签署",占同期收治患者的7.2%,其中68.6%为患者亲属方提出。86例患者高龄且疾病严重度高,53.5%的医疗费用为公费医疗。"签署"至死亡/转出ICU中位数时间41 h,ICU病死率80.2%。"签署"后死亡的患者,占同期死亡患者的30.9%。"签署"主要原因为病情无法逆转和希望减轻痛苦。3组患者疾病严重度、住ICU平均费用差异无统计学意义。C组病死率(50.0%)显著低于A组(89.5%)和B组(91.1%)。"签署"后至死亡/转出ICU间的医疗费用中位数,B组显著低于A组和C组(105.0元/h vs 220.0元/h,160.7元/h,P=0.001)。签署后至转出/死亡中位数时间,B组显著少于C组(24.0 h vs 73.5 h,P=0.000)。结论 ICU住院期间"签署"的比例较低,主要为高龄和疾病严重度高的患者。患者亲属方为主要提出方。"签署"后死亡患者仅占同期死亡患者1/3。撤离治疗在一定程度上降低医疗费用。

Objective To investigate the withholding and withdrawing of life supporting treatment in intensive care unit. Methods We undertook a prospective observational study in one Chinese university-hospital intensive care unit（ICU） between Jun 2009 and May 2011. Data were collected from all patients for whom decisions to withhold or withdraw life-supporting treatments were made, the data included age, sex, acute physiology and chronic health evaluation Ⅱ （APACHE Ⅱ ）, sequential organ failure assessment（ SOFA）, and previous chronic diseases. All patients were followed up until death or discharge from the ICU, and the length of ICU stay were recorded. Patients for whom such decisions were made were classified by the type of decision： group A was withheld, group B was withdrawn, group C was only DNR during dying. Results Totally 86 patients whose life support was withheld or withdrawn during the ICU duration were enrolled. That was 7.2% of the total admissions in the same period. These patients aged （76.6±12.5 ） years and 50.0% were male; 68.6% decisions were made by family request; 53.5% patients were covered by medical insurance. Death or discharge occurred 41.0 h after decision of withholding or withdrawing. During the study, 69 patients died in ICU （30.9% of all the ICU death） , ICU mortality was 80.2%. Compared to group A and C, group B had less surviving time and less medical expense. Conclusion The percentage of withholding or withdrawing of life-supporting treatment was not high in our ICU. The families were the major part who made the requests. Only One-third of the ICU deaths in our study were preceded by a decision to withhold or withdraw life-supporting treatment. Withdrawing life-support led to less medical expense.