Takmörkun meðferðar á gjörgæsludeild

Abstract

Background and objective: Increased medical and technical knowledge has saved the lives of more patients than was possible a few decades ago. This has also raised many ethical questions. It is now regarded to be justifiable to limit treatment for some terminally ill patients because certain treatment options are not felt to be in the patient's best interest. At The Reykjavik Hospital guidelines regarding the limitation of treatment were instituted in 1992. This study was undertaken to find out how these guidelines were implemented, how often treatment was limited, what reasons were given and how the documentation was carried out. Material and methods: Included were all patients in the intensive care unit for whom treatment was limited in the year 1993. When the decision was made to limit treatment a questionnaire was filled out. Information was recorded from this and the medical record. Results: There were 606 patients admitted to the intensive care unit in 1993. Decisions to limit treatment were made for 25 patients (4%). The mean age was 67.6 years. The reasons for limiting treatment were neurological deficit in 15 patients, multiple organ failure in seven patients and circulatory failure in three patients. The decision to limit treatment was made most frequently by the patient's primary hospital physician after consultation with the intensive care physician on call and the patient's relatives. Twenty-two of the patients were unconscious when the decision to limit treatment was made. Twenty-one died in the intensive care unit and four were discharged to a general patient ward. Discussion: Comparing our findings with those of similar studies in other countries it was found that the decision to limit care in our institution was made less frequently and, if made occurred later in the course of the patient's care. The documentation was considered to be less than optimal in some cases.

Inngangur: Aukin þekking í læknisfræði og tækni gerir kleift að bjarga lífi fleiri sjúklinga en áður. Ýmis siðfræðileg viðhorf hafa einnig breyst og við sérstakar aðstæður getur komið til álita að takmarka meðferð. Á Borgarspítalanum voru leiðbeiningar um takmörkun á meðferð formlega teknar upp árið 1992 og í framhaldi af því gerð könnun. Tilgangurinn var að athuga hversu oft takmörkun á meðferð sjúklinga var beitt á gjörgæsludeild, hverjar voru ástæður, hverjir tóku ákvörðunina, hvernig skráningu var háttað og hvernig leiðbeiningarnar voru notaðar. Efniviður og aðferðir: Sjúklingar á gjörgæsludeild spítalans sem fengu takmarkaða meðferð árið 1993. Þegar slík ákvörðun lá fyrir var fyllt út til þess gert eyðublað sem síöan var yfirfarið ásamt sjúkraskrám viðkomandi sjúklinga. Niðurstöður: Árið 1993 innrituðust 606 sjúklingar á gjörgæsludeild Borgarspítalans. Meðferð var takmörkuð hjá 25 sjúklingum (4%). Meðalaldur var 67,6 ár. Ástæður fyrir takmörkun á meðferð voru vanstarfsemi taugakerfisins í 15 tilfellum, sjö sinnum vegna fjölkerfabilunar og þrisvar vegna vanstarfsemi hjartans. Flestir sjúklinganna lögðust strax á gjörgæsludeild við komu á spítalann. Ákvörðun um takmörkim meðferðar tók sérfræðingur þeirrar deildar sem sjúklingur var skráður á, oftast í samráði við gjörgæslulækni og ættingja. Þegar ákvörðunin var tekin voru 22 sjúklingar án meðvitundar. Tuttugu og einn sjúklingur lést á gjörgæsludeild, fjórir útskrifuðust á legudeildir. Umræða: Miðað við erlendar kannanir er takmörkun meðferðar beitt sjaldnar hér og síðar í veikindum sjúklings. Skráning mætti vera ítarlegri í sumum tilfellum