急诊患者放弃有创抢救的原因分析及处理对策

Analysis and corresponding strategy of emergency patients forgoing the invasive rescue therapy

目的分析急诊患者放弃有创抢救的原因并提出对策。方法选择2014年1月至2014年12月收入北京协和医院急诊抢救室的2673例患者，分为抢救组和放弃抢救组，对两组患者的基本情况、基础疾病、医疗费用支付方式、签署意见书的人员构成、患者的治疗情况以及预后进行分析。结果两组患者男女性别构成差异无统计学意义（x^2=1．86，P=0．173）；放弃抢救组患者年龄明显高于抢救组患者（69．5±12．5 vs．58．6±19．2岁，F=28．92，P=0．000）；放弃抢救组中北京以外的患者比例更高（51．90％ vs 44．01％，x^2=10．59，P=0．001）；放弃抢救组中患慢性心衰、慢性呼吸衰竭、慢性肝性脑病、慢性肾衰竭、恶性肿瘤等慢性疾病的比例更高（8．17％ vs ．3．03％，8．17％ vs ．2．61％，3．80％ vs ．1．16％，5．32％ vs．1．44％，11．98％ vs．2．28％，均P=0．000）；放弃抢救组中白费患者比例更高（52．09％vs．41．08％，x^2=20．87，P=0．000）；在签署意见书的人员构成方面，由患者本人签署的放弃抢救的比例明显高于同意抢救（3．04％ vs．0．42％，x^2=64．40，P=0．000），而患者的子女、配偶、父母、兄弟姐妹以及其他人员签署的同意抢救和放弃抢救的比例差异无统计学意义；Logistic回归分析结果显示患者高龄、非北京患者、患慢性基础病、自费、由患者本人签署意见书是放弃有创抢救的重要影响因素；放弃抢救组患者的病死率明显高于抢救组（19．39％ vs．7．68％，x^2=64．40，P=0．000）。结论放弃有创抢救治疗的患者多为高龄或属于慢性疾病终末期，急诊医务人员应继续关注这些患者，采用无创的手段进行治疗或减轻患者的痛苦。

Objective To analyze the reasons of the emergency patients forgoing the invasive rescue therapy and to put forward the corresponding strategy. Methods According to whether the patients accepted the invasive rescue therapy or not, 2 673 patients in resuscitation room of Peking Union Medical College Hospital were divided into rescue group （group R） and do not rescue group （group DNR）. There were 2 147 cases in group R and 526 case in group DNR. The rescue consent form or do not rescue consent form was required to sign by patient self, patient＇ s family member or relatives. The patient＇ s basic information, underlying disease, payment of medical expenses, personnel who signed the consent form, treatment and prognosis in both groups were investigated. Results There was no significant gender deference in both groups （ x^2 = 1.86, P = 0. 173 ） . The mean age of patients in group DNR was much higher than that in group R （69. 5 ± 12. 5 vs. 58. 6 ±19.2 years, F =28.92, P =0. 000）. The proportion of patients outside Beijing in group DNR was higher than that of group R （51.90% vs. 44. 01%, x^2 = 10. 59, P =0. 001 ）. The ratios of chronic heart failure, chronic respiratory failure, chronic hepatic encephalopathy, chronic renal failure, malignant tumor in group DNR were significantly higher than that of group R （8. 17% vs. 3.03% , 8.17% vs. 2.61%, 3.80% vs.1. 16%, 5.32% vs. 1.44%, 11.98% vs. 2.28%, all P =0.000）. The proportion of patients without insurance in group DNR was higher than that of group R （52. 09% vs. 41.08% , x^2 =20. 87, P =0. 000）. Except the ratio of patients self signing the consent form in group DNR was higher than that of group R （3.04%vs. 0.42%, x^2 =64.40, P=0.000）, there were no significant deference in other people who signed the consent form such as patient＇s offspring, spouse, parents, siblings and others. Univariate and multivariate logistic regression analyses showed older age, non Beijing patients, chronic underlying diseases, without insurance and patients self signing the consent form were the major risk factors on refusing the invasive rescue therapy. The mortality rate of group DNR was much higher than that of group R （19.39% vs. 7.68%, x^2 =64.40, P=0.000）. Conclusions Most of patients who refused to accept invasive rescue therapy were elderly people or in condition of end stage of chronic disease. The doctors and nurses in emergency department should continue to take care of these patients and make use of noninvasive methods to treat them or relieve their pain.