Related Experiment Video
Updated: Feb 28, 2026
Minimally Invasive Endoscopic Intracerebral Hemorrhage Evacuation
Published on: October 15, 2021
Emergency department DNR order in patients with spontaneous intracerebral hemorrhage
Ju-Sing Fan1, Hsien-Hao Huang1, Yen-Chia Chen1
1Department of Emergency Medicine, Taipei Veterans General Hospital, Taipei, Taiwan, ROC; School of Medicine, National Yang-Ming University, Taipei, Taiwan, ROC.
Insights
Older, sicker spontaneous intracerebral hemorrhage (SICH) patients are more likely to receive emergency department do-not-resuscitate (ED-DNR) orders. While initial mortality is similar, ED-DNR orders correlate with increased mortality within 90 days but not neurological improvement.
Area of Science:
- Neurology
- Critical Care Medicine
- Public Health
Background:
- Spontaneous intracerebral hemorrhage (SICH) is a critical condition often requiring rapid medical decisions.
- Emergency department do-not-resuscitate (ED-DNR) orders represent crucial end-of-life care choices made during acute SICH events.
- Understanding factors influencing ED-DNR orders and their prognostic implications is vital for patient care and resource allocation.
Purpose of the Study:
- To identify key factors determining the issuance of ED-DNR orders in SICH patients.
- To evaluate the prognostic significance of ED-DNR orders on patient outcomes, including mortality and neurological status.
- To provide insights into end-of-life care decision-making in the emergency department setting for SICH.
Main Methods:
- A retrospective analysis of consecutive adult SICH patients admitted to the emergency department (ED) between 2012 and 2016.
- Logistic regression analysis to determine significant factors associated with ED-DNR order placement.
- Assessment of 30-day and 90-day neurological outcomes and mortality rates in patients with and without ED-DNR orders.
Main Results:
- 12.1% of 835 SICH patients received ED-DNR orders.
- Determinants for ED-DNR included older age, pre-event ambulatory status, midline shift, intraventricular extension, larger hematoma size, and low GCS score on ED arrival.
- While 30-day mortality was similar across initial ICH scores, ED-DNR patients showed increased 30-90 day mortality but similar neurological improvement rates.
Conclusions:
- Older and more clinically severe SICH patients exhibit a higher likelihood of receiving ED-DNR orders.
- ED-DNR orders did not significantly alter mortality rates when stratified by initial ICH score.
- No significant difference in neurological improvement was observed between patients with and without ED-DNR orders during the 30-90 day follow-up period.
Objectives:
To explore the determinant factors and prognostic significance of emergency department do-not-resuscitate (ED-DNR) orders for patients with spontaneous intracerebral hemorrhage (SICH).
Methods:
Consecutive adult SICH patients treated in our ED from January 1, 2012 to December 31, 2016 were selected as the eligible cases from our hospital's stroke database. Patients' information was comprehensively reviewed from the database and medical and nursing charts. ED-DNR orders were defined as DNR orders written during ED stay. Multiple logistic regression analysis was used to identify significant determinants of ED-DNR orders. Thirty- and 90-day neurological outcomes were analyzed to test the prognosis impact of ED-DNR orders.
Results:
Among 835 enrolled patients, 112 (12.1%) had ED-DNR orders. Significant determinant factors of ED-DNR orders were age, ambulatory status before the event, brain computed tomography findings of midline shift, intraventricular extension, larger hematoma size, and ED arrival GCS ≤8. Patients with and without ED-DNR orders had a similar 30-day death rate if they had the same initial ICH score point. During 30 to 90days, patients with ED-DNR orders had a significantly increased mortality rate. However, the rate of improvement in neurological status between the two groups was not significantly different.
Conclusions:
Older and sicker SICH patients had higher rate of ED-DNR orders. The mortality rates between patients with and without ED-DNR orders for each ICH score point were not significantly different. During the 30-to-90-day follow-up, the rates of neurological improvement in both groups were similar.
