院內心跳停止急救恢復自發性循環病人DNR之現況分析

Current Analysis Over DNR of ROSC (Return of Spontaneous Circulation) Patients of IHCA (In-Hospital Cardiac Arrest)

10.6537/TJHPC.201711_22(3).001

馬瑞菊(Jui-Chu Ma)；林佩璇(Pei-Xuan Lin)；黃琬庭(Wan-Ting Huang)；李佳欣(Chin-Hsin Li)；鄭婉如(Wan-Ju Cheng)；林芸兌(Yun-Tui Lin)；蕭嘉瑩(Chia-Ying Hsiao)；蘇珉一(Min-I Su)

院內心跳停止 ； 恢復自發性循環 ； 不施行心肺復甦術 ； 緩和醫療照護 ； in-hospital cardiac arrest ； return to spontaneous circulation ； Do Not Resuscitation ； Palliative care

安寧療護雜誌

22卷3期（2017 / 11 / 01）

257 - 272

繁體中文

研究目的：探討不施行心肺復甦術(DNR)在院內心跳停止病人之現況。材料與方法：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)期間發生院內心跳停止施行心肺復甦之365 位病人資料進行分析。結果：CPR 病人共有365 人，中有208 人(佔57%)恢復自發性循環(Return of spontaneous circulation, ROSC )、有27.7%發生再次CPR。CPR 最後死亡者有306 人(佔83.8%)、有59 人(16.2%)存活。在存活之59 人中其出院時意識清醒且能自由活動者有22 人(佔37.3%)，而意識不清、臥床需他人照顧者共37 人(佔62.7%)。ROSC 後醫療團隊與家屬有討論DNR 者為96 人(佔50.3%)。而有討論DNR 者其住院中再次發生CPR 的比率較未討論DNR 者為低(7.3%vs. 48.4%；P ＜ 0.001 )，且CPR 的總時間較短(12.9 分鐘 vs. 23.0 分鐘；P ＜ 0.001 )達統計上顯著差異。結論：院內心跳停止施行心肺復甦之病人其住院總死亡率高達83.8%，且有1/4 的病人發生再次CPR，而有DNR 討論者可以降低再次CPR 的比率與CPR 時間，因此建議醫療人員對於院內心跳停止施行心肺復甦之病人，介入DNR 討論方能使得家屬了解醫療現況並減少再次CPR 的比率與時間。

Purpose: To discuss the current condition of IHCA patients with DNR. Materials: The survey is designed using medical e-records from Jan 1^(st) 2012 to Dec 31^(st) 2015 to analyze the information of 365 IHCA patients with CPR. Results: There are 208 (57%) of 365 patients with CPR recovered to ROSC (Return to Spontaneous Circulation, 27.7% in need of re-CPR and 306 (83.8%) of them dead. Amid the 59 alive patients, there are 22 people (37.3%) with conscience and ability to move freely and the rest 37 people (62.7%) are unstable and in bed in need of attention. The rate of re-CPR of those having discussed DNR is lower than that of those having no discussion over DNR (7.3% vs. 48.4%; p = 0.000) and the time on CPR of those having discussed DNR is significantly shorter (12.9 minutes vs. 23.0 minutes; p = 0.000). Conclusion： The rate of in-hospital death of IHCA patients with CPR is 83.8% and 1/4 of patients had re-CPR, but those having discussed DNR can lower down the rate and time of re-CPR. Thus, it is recommended that medical staff insist in DNR discussion with families of those IHCA patients with CPR to make the condition crystal-clear and reduce the rate and time of re-CPR.

1. 洪韡倢,邱秀渝,洪芳明(2016)。外科重症病患生命末期 CPR 意願與家屬醫療決策之探討。安寧療護雜誌，21(3)，258-272。
   連結：
2. 趙可式(2015)。安寧療護是普世價值且為護理的本質。護理雜誌，62(2)，5-12。
   連結：
3. 羅文珮,洪韡倢(2015)。不予急救的決策與兩難。安寧療護雜誌，20(3)，296-305。
   連結：
4. 安寧緩和醫療條例。中華民國九十一年十二月十一日華總一義字第09100239020 號令修正公布第 3、7 條條文。91 年 11 月 11 日，取自http://www.tho.org.tw/xms/toc/list.php?courseID=14,2000
5. 立法院議案。立法院第 8 屆第 7 會期第 13 次會議議案關係文書。 104年 5 月 20 日，取自http://lci.ly.gov.tw/LyLCEW/agenda1/02/pdf/08/07/13/LCEWA01_080713_00034.pdf
6. Aacharya, RP,Mahajan, RK(2014).Ethical analysis of medical futility in cardiopulmonary resuscitation.J Clinic Res Bioeth,5(3),182.
7. Andersen, LW,Granfeldt, A,Callaway, CW(2017).Association between tracheal intubation during adult in-hospital cardiac arrest and survival.JAMA,1-13.
8. Chan, PS,Krein, SL,Tang, F(2016).Resuscitation practices associated with survival after in-hospital cardiac arrest: A nationwide survey.JAMA Cardiol,1(2),189-197.
9. Duplan, KL,Pirret, AM(2016).Documentation of cardiopulmonary resuscitation decisions in a New Zealand hospital: A prospective observational study.Intensive Crit Care Nurs,37,75-81.
10. Feingold, P,Mina, MJ,Burke, RM(2016).Long-term survival following in-hospital cardiac arrest: A matched cohort study.Resuscitation,99,72-78.
11. Girotra, S,Nallamothu, BK,Spertus, JA(2012).Trends in survival after in-hospital cardiac arrest.N Engl J Med,367(20),1912-1920.
12. Gulacti, U,Lok, U(2016).Influences of "do-not-resuscitate order" prohibition on CPR outcomes.Turk J Emerg Med,16(2),47-52.
13. Lin, MH,Peng, LN,Chen, LK,Chen, TJ,Hwang, SJ(2012).Cardiopulmonary resuscitation for hospital inpatients in Taiwan: an 8-year nationwide survey.Resuscitation,83(3),343-346.
14. Lippert, FK,Raffay, V,Georgiou, M,Steen, PA,Bossaert, L(2010).The ethics of resuscitation and end-of-life decisions.Resuscitation,81,1445-1451.
15. Liu, WL,Lai, CC,Hii, CH(2011).Outcomes and cost analysis of patients with successful in-hospital cardiopulmonary resuscitation.IJGE,5(4),196-199.
16. Merchant, RM,Yang, L,Becker, LB(2011).Incidence of treated cardiac arrest in hospitalized patients in the United States.Crit Care Med,39,2401-2406.
17. Perman, SM,Stanton, E,Soar, J(2016).Location of in-hospital cardiac arrest in the United States variability in event rate and outcomes.J Am Heart Assoc,5(10),1-7.
18. Piscator, E,Hedberg, P,Göransson, K,Djärv, T.(2016).Survival after in-hospital cardiac arrest is highly associated with the Age-combined Charlson Co-morbidity Index in a cohort study from a two-site Swedish University hospital.Resuscitation,99,79-83.
19. Sundar, S.(2016).Resuscitation is futile in terminally ill patients.BMJ,352.
20. 王梅(2010)。要趁早計劃 DNR 保障善終權只有 0.17％簽署。康健雜誌，141
21. 林慧美,楊嘉玲,陳美妙,邱泰源,胡文郁(2011)。住院病人簽屬預立醫療指示的意願及接受宣導的意向。安寧療護雜誌，16(3)，281-295。
22. 邱俊仁,徐國基,吳鋼治(2014)。以醫療品質突破系列提升院內心跳停止事件急救之照護品質。台灣醫學雜誌，18(2)，226-237。
23. 陳榮基(2013)。醫師應有主動拒絕實施心肺復甦術以維護病人善終的勇氣。安寧療護雜誌，18(1)，51-61。
24. 黃建華,陳文鍾(2009)。心跳停止及復甦急救後症候群之治療新觀念。醫學新知，1-8。
25. 衛生福利部中央健康保險署。102 年安寧緩和醫療條例部分條文修正案。102年 1 月 14 日，取自http://www.nhi.gov.tw/Resource/webdata/22983_2_102%E5%B9%B41%E6%9C%889%E6%97%A5%E7%B8%BD%E7%B5%B1%E4%BB%A4_%E5%AE%89%E5%AF%A7%E7%B7%A9%E5%92%8C%E9%86%AB%E7%99%82%E6%A2%9D%E4%BE%8B%E9%83%A8%E5%88%86%E6%A2%9D%E6%96%87%E4%BF%AE%E6%AD%A3.pdf
26. 蘇詠程。院內心跳停止的預防及處置。2017 年 02 月 17 日取自http://dlweb01.tzuchi.com.tw/tchw/Quality/files/%E5%93%81%E5%AE%89%E6%96%B0%E7%9F%A5/%E6%9C%AC%E9%99%A2%E9%86%AB%E5%93%81%E5%B0%88%E8%B2%AC%E9%86%AB%E5%B8%AB%E8%91%97%E4%BD%9C/%E9%99%A2%E5%85%A7%E5%BF%83%E8%B7%B3%E5%81%9C%E6%AD%A2%E7%9A%84%E9%A0%90%E9%98%B2%E5%8F%8A%E8%99%95%E7%BD%AE.pdf

1. 蔡佩珊,高綺吟,孫婉娜,卓季璇(2021)。運用跨團隊資源協助一位急救後恢復自發性心跳病人及家屬之護理經驗。領導護理，22(1)，54-67。