Do-Not-Resuscitate (DNR) Orders in Patients with Intracerebral Hemorrhage

Abstract

Background and purpose

Do-not-resuscitate orders may be associated with poor outcome in patients with intracerebral hemorrhage because of less active management.

Aims

We sought to characterize the practice of issuing do-not-resuscitate orders in intracerebral hemorrhage. We also aimed to identify possible differences in care according to do-not-resuscitate status.

Methods

We conducted a retrospective study of all consecutive intracerebral hemorrhage patients admitted to the Meilahti Hospital of the Helsinki University Central Hospital between January 2005 and March 2010. Data obtained from medical records allowed comparison of characteristics of patients and care of do-not-resuscitate and non-do-not-resuscitate patients as well as patients with early (within 24 h) and late (>24 h) do-not-resuscitate decisions. Logistic regression was used to identify factors independently associated with do-not-resuscitate decisions.

Results

Of our 1013 patients, a do-not-resuscitate order was issued in 368 (35%), of which 262 (73%) occurred within 24 h from admission. Advanced age (odds ratio 1.06 per year; 95% confidence interval 1.04–1.08), more severe stroke (1.09 per National Institutes of Health Stroke Scale point; 1.06–1.13), and deterioration soon after admission (5.12, 3.33–7.87) had the strongest associations with do-not-resuscitate decisions. Patients with do-not-resuscitate orders received recommended care including stroke unit care (43% vs. 64%; P < 0.001) and prophylaxis for deep venous thrombosis (45% vs. 54%; P = 0.027) less often than non-do-not-resuscitate patients. This was especially the case when the do-not-resuscitate order was issued early.

Conclusions

In addition to confirming the role of known intracerebral hemorrhage prognostic factors in do-not-resuscitate decision-making, our results demonstrate that do-not-resuscitate orders led to less active care of intracerebral hemorrhage patients.

Keywords

do-not-resuscitate intracerebral hemorrhage prognosis

Get full access to this article

View all access options for this article.

References

Becker

Baxter

Cohen

. Withdrawal of support in intracerebral hemorrhage may lead to self-fulfilling prophecies. Neurology 2001; 56:766–72.

Creutzfeldt

Becker

Weinstein

. Do-not-attempt-resuscitation orders and prognostic models for intraparenchymal hemorrhage. Crit Care Med 2011; 39:158–62.

Zahuranec

Brown

Lisabeth

. Early care limitations independently predict mortality after intracerebral hemorrhage. Neurology 2007; 68:1651–7.

Hemphill

3rd Newman

Zhao

Johnston

. Hospital usage of early do-not-resuscitate orders and outcome after intracerebral hemorrhage. Stroke 2004; 35:1130–4.

Beach

Morrison

. The effect of do-not-resuscitate orders on physician decision-making. J Am Geriatr Soc 2002; 50:2057–61.

Zahuranec

Morgenstern

Sanchez

Resnicow

White

Hemphill

3rd . Do-not-resuscitate orders and predictive models after intracerebral hemorrhage. Neurology 2010; 75:626–33.

Hemphill

3rd White

. Clinical nihilism in neuroemergencies. Emerg Med Clin North Am 2009; 27:27–37.

Broderick

Connolly

Feldmann

. Guidelines for the management of spontaneous intracerebral hemorrhage in adults: 2007 update: a guideline from the American Heart Association/American Stroke Association Stroke Council, High Blood Pressure Research Council, and the Quality of Care and Outcomes in Research Interdisciplinary Working Group. Circulation 2007; 116:e391–413.

Morgenstern

Hemphill

3rd Anderson

. Guidelines for the management of spontaneous intracerebral hemorrhage: a guideline for healthcare professionals from the American Heart Association/American Stroke Association. Stroke 2010; 41:2108–29.

10.

Meretoja

Strbian

Putaala

. SMASH-U – a proposal for etiologic classification of intracerebral hemorrhage. Stroke 2012; 43:2592–7.

11.

Williams

Yilmaz

Lopez-Yunez

. Retrospective assessment of initial stroke severity with the NIH Stroke Scale. Stroke 2010; 31:858–62.

12.

Kothari

Brott

Broderick

. The ABCs of measuring intracerebral hemorrhage volumes. Stroke 1996; 27:1304–5.

13.

Hemphill

3rd Bonovich

Besmertis

Manley

Johnston

. The ICH score: a simple, reliable grading scale for intracerebral hemorrhage. Stroke 2001; 32:891–7.

14.

Cheung

Zou

. Use of the original, modified, or new intracerebral hemorrhage score to predict mortality and morbidity after intracerebral hemorrhage. Stroke 2003; 34:1717–22.

15.

Alexandrov

Bladin

Meslin

Norris

. Do-not-resuscitate orders in acute stroke. Neurology 1995; 45:634–40.

16.

Keep

Hoff

. Mechanisms of brain injury after intracerebral haemorrhage. Lancet Neurol 2006; 5:53–63.

17.

Qureshi

. Intracerebral hemorrhage specific intensity of care quality metrics. Neurocrit Care 2011; 14:291–317.

18.

Diringer

Edwards

. Admission to a neurologic/neurosurgical intensive care unit is associated with reduced mortality rate after intracerebral hemorrhage. Crit Care Med 2001; 29:635–40.

19.

Meretoja

Kaste

Roine

. Trends in treatment and outcome of stroke patients in Finland from 1999 to 2007. PERFECT Stroke, a nationwide register study. Ann Med 2011; 43:S22–30.

20.

Meretoja

Roine

Kaste

. Stroke monitoring on a national level: PERFECT Stroke, a comprehensive, registry-linkage stroke database in Finland. Stroke 2010; 41:2239–46.

21.

Divani

Majidi

Luo

. ABCs of accurate volumetric measurement of cerebral hematoma. Stroke 2011; 42:1569–74.

22.

Hussein HM, Tariq NA, Palesch YY, Qureshi AI, for the ATACH Investigators. Reliability of hematoma volume measurement at local sites in a multicenter acute intracerebral hemorrhage clinical trial. Stroke 2013; 44:237–9.