Journal of Hospice and Palliative Care

  • 제19권1호
  • /
  • Pages.26-33
  • /
  • 2016
  • /
  • 2765-3072(pISSN)
  • /
  • 2765-3080(eISSN)
한국호스피스완화의료학회 (Korean Society for Hospice and Palliative Care)
권호 표지
DOI QR코드

DOI QR Code

심폐소생술금지 결정 시점에서의 임상적 특성: 일개 종합병원 종양내과 사망한 암환자를 대상으로

Clinical Characteristics of Oncologic Patients with DNR Decision at a Tertiary Hospital

  • 투고 : 2015.09.21
  • 심사 : 2016.02.04
  • 발행 : 2016.03.01
PDF 다운로드
⟨ 이전 논문 다음 논문 ⟩

초록

목적: 본 연구의 목적은 심폐소생술금지 지시에 동의한 시점에서 말기암환자의 임상적 특성을 확인하기 위한 후향적 서술조사 연구이다. 방법: A 종합병원 종양내과에서 2013년 1월부터 12월까지 사망한 환자 중에서 DNR 지시에 동의한 197명을 대상으로 전자의무기록을 조사하였다. 조사 내용은 입원 당시 대상자의 일반적 특성과 임상적 특성, DNR 지시에 동의한 시점에서의 대상자의 상태를 활력징후, 의식상태, 시행 중인 치료였으며, 수집된 자료는 SPSS win 21.0 프로그램을 이용하여 분석하였다. 결과: 대상자의 평균 나이는 58.7세였고, 남자가 121명(61.4%)이었고, 소화기계 암환자가 94명(47.7%)으로 가장 많이 포함되었다. 대상자의 평균 재원기간은 19.61일이었고, DNR 지시에 동의서를 작성한 시점은 입원일로부터 평균 12.95일이었으며, 사망까지 이른 시간은 평균 6.66일이었다. DNR 동의시점에서 대상자의 66.0%가 호흡기계부전을 가지고 있었으며, 불안정한 활력징후를 147명(74.6%)에서 보였으며, 의식수준의 변화가 있는 91명(46.2%)에서 있었다. DNR 동의서 작성 당시 대상자의 의식 상태는 명료 53.8% (106명), 기면 20.8% (41명), 혼돈 16.8% (33명), 혼수 8.6% (17명)이었다. 결론: 대부분 DNR 결정과 관련된 설명이나 의사 결정 시기에서 환자의 의식수준, 활력증후, 산소포화도가 불안정한 상태였으며, 대부분 위중한 상태 또는 환자의 판단능력이 상실된 시점에서 이루어지면서 환자의 참여가 제한되었다. 말기암환자의 자율성 향상 및 적절한 치료 중단 시점을 규정하기 위한 제도적인 장치 마련이 시급하다.

Purpose: This study was conducted to identify clinical characteristics of oncologic patients at a point when they signed their do-not-resuscitate (DNR) orders. Methods: From January through December 2014, we retrospectively analyzed the records of 197 patients who passed away after agreeing to a DNR order in the hemato-oncology department of a tertiary hospital. Results: Of all, 121 patients (61.4%) were male and 76 (38.6%) were female, and their average age was 58.7 years. Ninety-four patients (47.7%) had gastrointestinal cancer. The ECOG performance status at admission was grade 3 in 76 patients (36.5%) and grade 4 in 11 (5.6%). The patients' mean hospital stay was 20 days. The mean duration from the admission to DNR decision was 13 days, and the mean duration from DNR decision to death was seven days. Conclusion: Study results indicate that a decision on signing or refusing a DNR order was made by medical staff mostly based on the opinions of patients' guardians rather than the patients themselves. This suggests that patients' own wishes are not well respected. Thus, it is urgent to establish institutional devices to enhance cancer patients' autonomy regarding DNR and to define an adequate timing for withdrawal of treatments.

키워드

참고문헌

  1. Yu HJ. The basis and conditions of justified withdrawing or withholding of persistence-treatment. Korean J Med Ethics 2002;5:151-67.
  2. Cheong HY, Sohn MS, Heo DS, Lee WH. Justifying the information on hospice care that doctors should provide to terminally ill patients. Korean J Med Ethics 2010;13:107-22.
  3. Brink P, Smith TF, Kitson M. Determinants of do-not-resuscitate orders in palliative home care. J Palliat Med 2008;11:226-32. https://doi.org/10.1089/jpm.2007.0105
  4. Han SS, Kim JH, Ku IH, Hong SY, Lee KS. Development of the guideline to Do-Not-Resuscitate (DNR) and ethical review. Korean J Med Ethics Educ 2005;8:116-30.
  5. Koh Y, Heo DS, Yun YH, Moon JL, Park HW, Choung JT, et al. Charactersitics and issues of guideline to withdrawal of a life-sustaining therapy. J Korean Med Assoc 2011;54:747-57. https://doi.org/10.5124/jkma.2011.54.7.747
  6. Oh DY, Kim JH, Kim DW, Im SA, Kim TY, Heo DS, et al. CPR or DNR? End-of-life decision in Korean cancer patients: a single center's experience. Support Care Cancer 2006;14:103-8. https://doi.org/10.1007/s00520-005-0885-5
  7. Bailey FA, Allen RS, Williams BR, Goode PS, Granstaff S, Redden DT, et al. Do-not-resuscitate orders in the last days of life. J Palliat Med 2012;15:751-9. https://doi.org/10.1089/jpm.2011.0321
  8. Jo KH, Kim GM. Predictive factors affecting the preferences for care near the end of life among nurses and physicians. Korean J Med Ethics 2010;13:305-20.
  9. Lee KH, Jang HJ, Hong SB, Lim CM, Koh YS. Do-notresuscitate order in patients, who were deceased in a medical intensive care unit of an university hospital in Korea. Korean J Crit Care Med 2008;23:84-9. https://doi.org/10.4266/kjccm.2008.23.2.84
  10. Lee SM, Kim SY, Lee HS. The process of medical decision-making for cancer patients. Korean J Med Ethics 2009;12:1-14.
  11. Hwang IC, Choi CH, Kim KK, Lee KS, Suh HS, Shim JY. Predictability of impending events for death within 48 hours in terminal cancer patients. Korean J Hosp Palliat Care 2011;14: 28-33.
  12. Lee KW, Lee JH, Choi YJ, Lee TK, Kim SS, Shin HJ, et al. Analysis of deaths of the patients with terminal cancer. Korean J Med 2003;65:66-70.
  13. Henriksen DP, Brabrand M, Lassen AT. Prognosis and risk factors for deterioration in patients admitted to a medical emergency department. PLoS One 2014;9:e94649. https://doi.org/10.1371/journal.pone.0094649
  14. Barfod C, Lauritzen MM, Danker JK, Soletormos G, Forberg JL, Berlac PA, et al. Abnormal vital signs are strong predictors for intensive care unit admission and in-hospital mortality in adults triaged in the emergency department-a prospective cohort study. Scand J Trauma Resusc Emerg Med 2012;20:28. https://doi.org/10.1186/1757-7241-20-28
  15. Maltoni M, Caraceni A, Brunelli C, Broeckaert B, Christakis N, Eychmueller S, et al. Prognostic factors in advanced cancer patients: evidence-based clinical recommendations-a study by the Steering Committee of the European Association for Palliative Care. J Clin Oncol 2005;23:6240-8. https://doi.org/10.1200/JCO.2005.06.866
  16. Parsons HA, de la Cruz MJ, Zhukovsky DS, Hui D, Delgado-Guay MO, Akitoye AE, et al. Characteristics of patients who refuse do-not-resuscitate orders upon admission to an acute palliative care unit in a comprehensive cancer center. Cancer 2010; 116:3061-70. https://doi.org/10.1002/cncr.25045
  17. Stein RA, Sharpe L, Bell ML, Boyle FM, Dunn SM, Clarke SJ. Randomized controlled trial of a structured intervention to facilitate end-of-life decision making in patients with advanced cancer. J Clin Oncol 2013;31:3403-10. https://doi.org/10.1200/JCO.2011.40.8872
  18. Kim MH, Kang EH, Kim MY. Family decision-making to withdraw life-sustaining treatment for terminally-ill patients in an unconscious state. Korean J Hosp Palliat Care 2012;15:147-54.
  19. Hilden HM, Louhiala P, Palo J. End of life decisions: attitudes of Finnish physicians. J Med Ethics 2004;30:362-5. https://doi.org/10.1136/jme.2002.001081
  20. McNamee J, O'Keeffe ST. Documentation of do-not-resuscitate orders in an Irish hospital. Ir J Med Sci 2004;173:99-101. https://doi.org/10.1007/BF02914567
  21. Heo DS. Patient autonomy and advance directives in Korea. J Korean Med Assoc 2009;52:865-70. https://doi.org/10.5124/jkma.2009.52.9.865
  22. Yun YH, Kwak M, Park SM, Kim S, Choi JS, Lim H-Y, et al. Chemotherapy use and associated factors among cancer patients near the end of life. Oncology 2007;72:164-71. https://doi.org/10.1159/000112802

피인용 문헌

  1. 국내 일개 2차 병원의 암환자 치료 실태 vol.21, pp.3, 2018, https://doi.org/10.14475/kjhpc.2018.21.3.84
  2. 만성 심폐질환을 가진 말기 노인 환자의 연명의료 의사결정의 번복 및 관련 요인 vol.49, pp.3, 2016, https://doi.org/10.4040/jkan.2019.49.3.329
  3. Effects of Advance Care Planning on End-of-Life Decision Making: A Systematic Review and Meta-Analysis vol.23, pp.2, 2016, https://doi.org/10.14475/kjhpc.2020.23.2.71
  4. Life-Sustaining Treatment in End-Stage Liver Disease Patients: Patients' Decisions and Results vol.23, pp.2, 2016, https://doi.org/10.14475/kjhpc.2020.23.2.85