DO-NOT-RESUSCITATE ORDERS IN ACUTE STROKE

Although the general guidelines for do-not-resuscitate (DNR) orders ap ply to acute stroke patients, few data are available to aid decision-m aking. With a view to developing specific guidelines for use in patien ts with acute stroke, we decided to evaluate the clinical factors asso ciated with DNR orders at our university teaching hospital. We prospec tively studied 450 consecutive patients with acute hemispheric strokes (237 men and 213 women, mean age 75 +/- 12 years). Thirty-six patient s (8%) had intracerebral hemorrhage (ICH) and 414 (92%) had ischemic s trokes. Overall inhospital mortality was 26%. DNR status was given to 31% of all patients at some time during their admission (83% of those died). DNR decision-making was closely associated with the severity of the neurologic deficit (Canadian Neurological Scale score less than o r equal to 5); the patient's incapacity for informed DNR decision-maki ng; age (>60 years); and devastating ICH unsuitable for surgery (p < 0 .001). Fifty-three percent of DNR orders were given on admission (firs t 24 hours of the hospital stay), 35% during the first week of the hos pital stay, due to brain damage, and 12% at any time between days 8 an d 44 due to systemic complications. Once DNR status was given, 53% of patients continued to receive normal nutrition and 60% still received medical or surgical treatment. Although the current practice of DNR or ders in patients with acute stroke is generally satisfactory, some cri teria leg, age and operable ICH) need revision. Following the decision to withhold CPR, patients with severe stroke, irreversible brain dama ge, and/or significant comorbidities should receive DNR status wheneve r the prognosis has become clear for physicians and family. We suggest provisional disease-specific criteria for DNR decision-making in acut e stroke.