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Published on: February 8, 2022
Early care limitations independently predict mortality after intracerebral hemorrhage
D B Zahuranec1, D L Brown, L D Lisabeth
1Stroke Program, University of Michigan Medical School, Ann Arbor, MI 48109-0316, USA.
Insights
Early limitations in aggressive care, including do not resuscitate (DNR) orders, significantly increase mortality risk for patients with intracerebral hemorrhage (ICH). This finding highlights the need for careful consideration of care limitations to improve survival rates.
Area of Science:
- Neurology
- Public Health
- Critical Care Medicine
Background:
- Intracerebral hemorrhage (ICH) presents a significant challenge due to its high early mortality rate.
- Early decisions regarding limitations in aggressive care can profoundly influence patient outcomes.
Purpose of the Study:
- To investigate the impact of early do not resuscitate (DNR) orders and other care limitations on mortality following intracerebral hemorrhage (ICH).
Main Methods:
- A community-based study identified spontaneous ICH cases from 2000-2003.
- Early (<24 hours) combined DNR (C-DNR) orders were analyzed for association with mortality using multivariable Cox-proportional hazards models.
- Adjustments were made for demographics and established ICH mortality predictors.
Main Results:
- Of 270 ICH cases, 34% had early C-DNR orders.
- Early C-DNR was associated with a doubled hazard of death at 30 days (HR 2.17) and end of follow-up (HR 1.92).
- These associations persisted despite adjustment for key clinical and demographic factors.
Conclusions:
- Early limitations in aggressive care are independently linked to increased short- and long-term mortality in ICH patients.
- Physicians must carefully evaluate the implications of early care limitations to prevent premature withdrawal of potentially life-saving interventions.
- Consideration of patient prognosis versus the impact of care limitations is crucial for optimizing outcomes in ICH.
Objective:
Intracerebral hemorrhage (ICH) is associated with a high early mortality rate. We examined the impact of early do not resuscitate (DNR) orders and other limitations in aggressive care on mortality after ICH in a community-based study.
Methods:
Cases of spontaneous ICH from 2000 to 2003 were identified from the Brain Attack Surveillance in Corpus Christi (BASIC) project, with deaths ascertained through 2005. Charts were reviewed for early (<24 hours from presentation) DNR orders, withdrawal of care, or deferral of other life sustaining interventions, analyzed together as combined DNR (C-DNR). Multivariable Cox-proportional hazards models were used to examine the association between short- and long-term all-cause mortality and early C-DNR, adjusted for demographics and established predictors of mortality after ICH.
Results:
Of 18,393 subjects screened for cerebrovascular disease, 270 non-traumatic ICH cases were included. Cumulative mortality risk was 0.43 at 30 days and 0.55 over the study course. Early C-DNR was noted in 34% of cases and was associated with a doubling in the hazard of death both at 30 days (hazard ratio [HR] 2.17, 95% CI 1.38, 3.41) and at end of follow-up (HR 1.92, 95% CI 1.29, 2.87) despite adjustment for age, gender, ethnicity, Glasgow Coma Scale, ICH volume, intraventricular hemorrhage, and infratentorial hemorrhage.
Conclusions:
Early care limitations are independently associated with both short- and long-term all-cause mortality after intracerebral hemorrhage (ICH) despite adjustment for expected predictors of ICH mortality. Physicians should carefully consider the effect of early limitations in aggressive care to avoid limiting care for patients who may survive their acute illness.
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