📋 护理管理 · 第3课，共7课 · 6 min
生前遗嘱、代理人和并非“不治疗”的 DNR
Living Wills, Proxies and the DNR That Is Not 'Do Not Treat'
📜 “DNR”并不意味着“不护理”。一位有 DNR 医嘱的患者仍然会接受抗生素、疼痛控制、吸氧和你的全心关注。考试会考你是否知道这个医嘱真正停止的是什么。
📜 'DNR' does not mean 'do not care'. A client with a DNR order still gets antibiotics, pain control, oxygen and your full attention. The exam tests whether you know what the order actually stops.
💡 核心要点
预立医疗指示只在患者无法发声时才发声。DNR 只停止 CPR，其他什么都不停止；除非另行拒绝，否则其他所有治疗都会继续。
Advance directives speak only when the client cannot. A DNR stops CPR and nothing else; every other treatment continues unless separately refused.
🧠 为什么重要
生前遗嘱说明患者在无法为自己发声时想要或拒绝哪些治疗，例如呼吸机或管饲。医疗保健持久授权书（health care proxy，医疗保健代理人）指定一个人在患者无法做决定时代为做决定。两者都只在患者丧失决策能力时才生效；仍然能够自己做决定的患者可以推翻任何文件。不复苏（DO-NOT-RESUSCITATE）医嘱是医疗服务提供者根据患者意愿下达的医嘱，在心脏或呼吸骤停时不进行 CPR。它并不取消其他治疗：舒适护理、药物、吸氧、吸痰和手术都可以继续。护士在入院时询问预立医疗指示的情况，将复印件放入病历中，并在家属的意愿与有行为能力的患者已记录的选择发生冲突时进行倡导。
A LIVING WILL states what treatments a client wants or refuses if they cannot speak for themselves, such as ventilation or tube feeding. A DURABLE POWER OF ATTORNEY FOR HEALTH CARE (health care proxy) names a person to make decisions when the client cannot. Both take effect only when the client loses decision-making capacity; a client who can still make decisions overrides any document. A DO-NOT-RESUSCITATE order is a provider's order, based on the client's wishes, that withholds CPR in cardiac or respiratory arrest. It does NOT withhold other treatment: comfort care, medications, oxygen, suctioning and surgery can all continue. Nurses ask about advance directives on admission, place copies in the record, and advocate when a family's wishes conflict with a competent client's documented choices.
🏥 真实场景
👨👩👧 一位有行为能力且有 DNR 医嘱的患者患上了肺炎。家属说：“他是 DNR，所以就让他舒服点就行了。”这位神志清楚、头脑清醒的患者要求使用抗生素。护士给予了医嘱中的抗生素。DNR 不是拒绝治疗，一位有行为能力的患者的声音比家属对一份表格的解读更有分量。
👨👩👧 A competent client with a DNR order develops pneumonia. The family says, 'He's DNR, so just keep him comfortable.' The client, alert and clear, asks for antibiotics. The nurse administers the ordered antibiotics. A DNR is not a refusal of treatment, and a capable client's voice beats the family's interpretation of a form.
📌 要点总结
- 生前遗嘱：我想要什么；代理人：谁替我做决定Living will: what I want; proxy: who decides for me
- 指示只在患者缺乏行为能力时才适用Directives apply only when the client lacks capacity
- DNR 只取消 CPR；其他所有护理都会继续DNR withholds CPR only; all other care continues
📖 本课术语
预立医疗指示 (Advance directive): 一份文件，说明患者在无法自行做决定时的治疗意愿，或指定一名决策者。
不予复苏医嘱（DNR） (Do-not-resuscitate order (DNR)): 提供者下达的在心脏或呼吸骤停时不进行CPR的医嘱；除非有单独医嘱或患者意愿加以限制，其他治疗继续进行。
✅ 自我测试
一位有 DNR 医嘱的患者因髋部骨折入院。以下哪位新护士的说法需要纠正？A client with a DNR order is admitted with a hip fracture. Which statement by a new nurse requires correction?
- “我们仍然会积极地控制疼痛。”'We will still manage the pain aggressively.'
- “如果患者同意，手术可以进行。”'Surgery can proceed if the client consents.'
- “如果患者的心脏停跳，我们不会开始 CPR，也不会呼叫抢救。”'If the client's heart stops, we do not start CPR or call a code.'
- “既然患者是 DNR，我们就不用费心用抗生素了。”'We shouldn't bother with antibiotics since the client is DNR.'
答案: D · “既然患者是 DNR，我们就不用费心用抗生素了。”
DNR 只适用于骤停时的复苏。抗生素、手术和舒适措施不受影响。
A DNR applies only to resuscitation in arrest. Antibiotics, surgery and comfort measures are not affected.
一位神志清醒、定向力正常的患者拒绝透析。患者的医疗保健代理人坚持要做透析。谁的决定有效？An alert, oriented client refuses dialysis. The client's health care proxy insists it be given. Whose decision stands?
- 医疗服务提供者的，因为他是医学专家The provider's, as the medical expert
- 家属多数人的，因为亲属最了解患者The family majority's, since relatives know the client best
- 患者的；代理人只在患者无法做决定时才行事The client's; the proxy acts only when the client cannot
- 代理人的，因为文件已经签字并公证了The proxy's, because the document was signed and notarized
答案: C · 患者的；代理人只在患者无法做决定时才行事
代理人只在患者无法做决定时才有权力。有行为能力的患者自己的选择起决定作用。
A proxy has authority only when the client cannot decide. A competent client's own choice controls.
哪份文件指定另一个人来做医疗保健决定？Which document names another person to make health care decisions?
- 在律师处备案的遗嘱Last will and testament filed with an attorney
- 提前说明治疗偏好的生前遗嘱Living will stating treatment preferences in advance
- 由医疗服务提供者签字的 DNR 医嘱DNR order signed by the provider
- 医疗保健持久授权书Durable power of attorney for health care
答案: D · 医疗保健持久授权书
医疗保健持久授权书（代理人）指定一位决策者；生前遗嘱记录治疗偏好。
A durable power of attorney for health care (proxy) appoints a decision-maker; a living will records treatment preferences.
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