Abstract
IntroductionIn former studies from North America early Do-Not–Resuscitate orders (DNR orders) in patients with intracerebral haemorrhage (ICH) had negative prognostic impact on mortality. The influence of DNR orders on functional outcome and whether DNR orders are grounded on relevant patient characteristics is unknown. We aimed to determine the frequency and predictive factors of DNR-orders and its association to prognosis, in ICH patients, in Scandinavia.MethodsIn 197 consecutive ICH patients admitted to Skåne University Hospital, Malmö, Sweden, between January 2007 and June 2009, information of the presence of DNR orders within 48 hours, clinical and radiological characteristics was retrieved by review of patient medical journal and computed tomography scans. Determinants of DNR-orders, one-month case fatality and bad functional outcome (modified Rankin Scale, grade 4–6) were assessed by logistic regression analysis.ResultsDNR orders were made in 41% of the cases. After adjustment for confounding factors, age ≥ 75 years (Odds Ratio (95% confidence interval) 4.2(1.8-9.6)), former stroke (5.1(1.9-3.1)), Reaction Level Scale grade 2–3 and 4 (7.0(2.8-17.5) and (4.1(1.2-13.5), respectively) and intraventricular haemorrhage (3.8(1.6-9.4)) were independent determinants of early DNR orders. Independent predictors of one-month case fatality was age ≥ 75 years (3.7(1.4-9.6)) volume ≥ 30 ml (3.5(1.3-9.6)) and DNR orders (3.5(1.5-8.6)). Seizure (6.0(1.04-34.2) and brain stem hemorrhage (8.0(1.1-58.4)) were related to bad functional outcome, whereas early DNR order was not (3.5(0.99-12.7)).ConclusionsWell known prognostic factors are determinants for DNR orders, however DNR orders are independently related to one-month case fatality. In addition to improvements of the local routines, we welcome a change of attitude with an enhanced awareness of the definition of, and a more careful approach with respect to DNR orders.
Highlights
In former studies from North America early Do-Not–Resuscitate orders (DNR orders) in patients with intracerebral haemorrhage (ICH) had negative prognostic impact on mortality
In 41% of the cases, DNR orders were made within 48 hours from arrival to the hospital, and 36% of the cases had a DNR order within 24 hours from arrival
Determinants of early DNR order Factors related to DNR order were age ≥ 75 years (Odds Ratio (OR) 95% confidence interval 2.7 (1.54.9)), former stroke (OR 3.3 (1.6-6.9)), Reaction level scale (RLS) grade 2–3 and 4 (OR 6.8(3.4-14.0) and 7.1(3.0-16.6), respectively), volume ≥ 30 ml (OR 3.9(2.0-7.6)), midlineshift (OR 7.2 (3.5-14.9) and the presence of intraventicular haemorrhage (OR 5.8 (3.1-11.2))
Summary
In former studies from North America early Do-Not–Resuscitate orders (DNR orders) in patients with intracerebral haemorrhage (ICH) had negative prognostic impact on mortality. Onemonth case fatality rate is high, 25-50% [3,4,5], as compared to 10% for cerebral infarction [6] With this knowledge of poor prognosis, physicians who receive acute ICH patients may raise questions about level of care decisions, sometimes with a palliative approach already in an early stage, in order to avoid exposing the patient from unnecessary suffering. Haemorrhagic characteristics and age are important prognostic factors [3,5] It has been shown, in North American studies, that Do- Not –Resuscitate orders (DNR orders) within 24 hours from admission predict mortality after ICH [10,11,12]. We aimed to determine the frequency and determinant factors of DNR orders within 48 hours from admission to hospital, and its association with one-month case fatality rate and three month functional outcome in patients with ICH at a University Hospital in Scandinavia
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