Do not resuscitate orders for cerebrovascular accident patients

Process of care and mortality of stroke patients with and without a do not resuscitate order in the West Midlands, UK

OBJECTIVE

. To compare the process of care of stroke patients with and without a do not resuscitate (DNR) order.

DESIGN

Retrospective case note review with prospective follow up of mortality.

SETTING

Seven acute hospitals, with stroke units, in the West Midlands, UK.

PARTICIPANTS

A random sample of patients (n = 702) admitted to hospital with acute stroke over a twelve month period.

MAIN OUTCOME MEASURES

Case mix and process of care measures derived from the intercollegiate stroke audit package. Thirty day and one year mortality.

RESULTS

About one-third (34%, 238/702) of stroke patients had DNR orders. The thirty-day mortality for DNR patients was 67% (160/238) versus 10% (46/449) for patients without DNR orders. DNR patients had significantly worse case-mix profile than non-DNR patients - median age 81 y vs 75y; fully conscious 36% vs 79%, able to walk 1% vs 21% and no loss of power in either arm 5% vs 24% (all p < 0.0001). DNR patients were more likely to be assessed early by a speech and language therapist (77% vs 59%, p < 0.001), but less likely to receive the majority of their care in a stroke/rehabilitation unit (20% vs 57%, p < 0.0001), or be cared for on a stroke unit or by a stroke team (42% vs 70%, p <0.0001), or had a description of the site of the cerebral lesion (31% vs 38%, p = 0.05) or be given aspirin (30% vs 42%, p = 0.007).

CONCLUSIONS

Stroke patients with a DNR order are not receiving optimum care in that they are not being cared for on stroke units or by specialist teams. This may reflect the inadequate provision of specialist stroke services in the UK.

Increased risk of death in patients with do-not-resuscitate orders

BACKGROUND

Whereas studies have shown higher mortality rates in patients with do-not-resuscitate (DNR) orders, most have not accounted for confounding factors related to the use of DNR orders and/or factors related to the risk of death.

OBJECTIVE

To determine the relationship between the use of DNR orders and in-hospital mortality, adjusting for severity of illness and other covariates.

DESIGN

Retrospective cohort study.

PATIENTS

There were 13,337 consecutive stroke admissions to 30 hospitals in 1991 to 1994.

MEASURES

To decrease selection bias, propensity scores reflecting the likelihood of a DNR order were developed. Scores were based on nine demographic and clinical variables independently related to use of DNR orders. The odds of death in patients with DNR orders were then determined using logistic regression, adjustment for propensity scores, severity of illness, and other factors.

RESULTS

DNR orders were used in 22% (n = 2,898) of patients. In analyses examining DNR orders written at any time during hospitalization, unadjusted in-hospital mortality rates were higher in patients with DNR orders than in patients without orders (40% vs. 2%, P<0.001); the adjusted odds of death was 33.9 (95% CI, 27.4-42.0). The adjusted odds of death remained higher in analyses that only considered orders written during the first 2 days (OR 3.7; 95% CI, 3.2-4.4) or the first day (OR 2.4; 95% CI, 2.0-2.9). In stratified analyses, adjusted odds of death tended to be higher in patients with lower propensity scores.

CONCLUSION

The risk of death was substantially higher in patients with DNR orders after adjusting for propensity scores and other covariates. Whereas the increased risk may reflect patient preferences for less intensive care or unmeasured prognostic factors, the current findings highlight the need for more direct evaluations of the quality and appropriateness of care of patients with DNR orders.