背景:生命维持治疗(LLST)的局限性导致伦理困境,即使在预后不良的患者中,这适用于许多进入神经重症监护病房(NCCU)的患者。在NCCU人群中,社会和文化方面对LLST的影响仍未得到充分研究。
方法:纳入2018年01月至08.2021年的所有NCCU患者。对医疗记录进行了审查:人口统计学,诊断,疾病的严重程度,和结果。预先指令(AD)和LLST讨论进行了审查,评估了时间安排,学位,和LLST的原因。社会/文化因素(国籍,口语,宗教,婚姻状况,与法定代表人的关系/性别)已注明。这些因素与患者性别之间的关联,LLST计时,并评估AD的存在。
结果:在2975名患者中,12%的男性和10.5%的女性接受了LLST(p=0.30)。女人,和男人相比,更常见的是接受戒断而不是扣留维持生命的治疗(57.5vs.45.1%,p=0.028),尽管疾病严重程度相当。接受LLST的女性年龄较大(73±11.7vs.69±14.9年,p=0.005),并且经常没有伴侣(43.8vs.25.8%,p=0.001)与男性相比。AD与女性和早期LLST有关,但没有增加住院死亡率(57.1vs.有和没有AD的患者分别为75.2%)。
结论:在接受LLST的患者中,AD的存在与早期LLST的增加有关,但住院死亡率却没有增加。这支持了以下观点:AD的存在主要是患者意愿的表达,但本身并不预示患者的不利结果。
BACKGROUND: The limitation of life sustaining treatments (LLST) causes ethical dilemmas even in patients faced with poor prognosis, which applies to many patients admitted to a Neurocritical Care Unit (NCCU). The effects of social and cultural aspects on LLST in an NCCU population remain poorly studied.
METHODS: All NCCU patients between 01.2018 and 08.2021 were included. Medical records were reviewed for: demographics, diagnosis, severity of disease, and outcome. Advance directives (AD) and LLST discussions were reviewed evaluating timing, degree, and reason for LLST. Social/cultural factors (nationality, language spoken, religion, marital status, relationship to/sex of legal representative) were noted. Associations between these factors and the patients\' sex, LLST timing, and presence of AD were evaluated.
RESULTS: Out of 2975 patients, 12% of men and 10.5% of women underwent LLST (p = 0.30). Women, compared to men, more commonly received withdrawal instead of withholding of life sustaining treatments (57.5 vs. 45.1%, p = 0.028) despite comparable disease severity. Women receiving LLST were older (73 ± 11.7 vs. 69 ± 14.9 years, p = 0.005) and often without a partner (43.8 vs. 25.8%, p = 0.001) compared to men. AD were associated with female sex and early LLST, but not with an increased in-hospital mortality (57.1 vs. 75.2% of patients with and without AD respectively).
CONCLUSIONS: In patients receiving LLST, the presence of an AD was associated with an increase of early LLST, but not with an increased in-hospital mortality. This supports the notion that the presence of an AD is primarily an expression of the patients\' will but does not per se predestine the patient for an unfavorable outcome.