Do-not-resuscitate (DNR) orders in patients with intracerebral hemorrhage

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.