AGREEMENT ON DISEASE-SPECIFIC CRITERIA FOR DO-NOT-RESUSCITATE ORDERS IN ACUTE STROKE

Background and Purpose The do-not-resuscitate (DNR) order is a mechani sm of withholding cardiopulmonary resuscitation (CPR). The lack of DNR guidelines specific for acute stroke may result in many stroke patien ts receiving unnecessary and futile resuscitation and ventilator-assis ted breathing. Methods A prospective multicenter evaluation of disease specific criteria for DNR orders in acute stroke was initiated using a modified Delphi process. The participants were the Canadian and West ern New York Stroke Consortium members who are closely involved in car ing for acute stroke patients and conducting clinical trials at the ac ademic centers. Previously published provisional criteria were reviewe d by the participants. Modifications were made to the criteria until s tatistically significant agreement (P<.05, z score, or 67% similar ans wers) was achieved. Results Disease-specific criteria for DNR orders i n acute stroke were discussed by 26 physicians in three rounds of the opinion survey. An agreement was reached that a ''no resuscitation'' d ecision is appropriate when any two of the following three clinical cr iteria are present (the degree of agreement is given in parentheses): severe stroke (88%, P=.00007), life-threatening brain damage (73%, P<. 01), and significant co-morbidities (92% P=.00003). The poor prognosis implied by these criteria should be discussed whenever possible among physician(s), the patient, and family members before the decision to withhold CPR is made. Eighty-one percent of the participants agreed th at these disease-specific criteria are appropriate for clinical use (P =.0008). Conclusions Disease-specific criteria for DNR orders were dev eloped to supplement general DNR policies for patients with hemispheri c brain infarction and intracerebral hemorrhage during the first 2 wee ks of stroke. A significant agreement was reached by a panel of physic ians that patients with acute stroke should not be resuscitated if the se disease-specific criteria are met.