Do-not-resuscitate Orders and Predictive Models After Intracerebral Hemorrhage

Neurology. 2010 Aug 17;75(7):626-33. doi: 10.1212/WNL.0b013e3181ed9cc9. Epub 2010 Jul 7.

Abstract

Objective: To quantify the accuracy of commonly used intracerebral hemorrhage (ICH) predictive models in ICH patients with and without early do-not-resuscitate orders (DNR).

Methods: Spontaneous ICH cases (n = 487) from the Brain Attack Surveillance in Corpus Christi study (2000-2003) and the University of California, San Francisco (June 2001-May 2004) were included. Three models (the ICH Score, the Cincinnati model, and the ICH grading scale [ICH-GS]) were compared to observed 30-day mortality with a chi(2) goodness-of-fit test first overall and then stratified by early DNR orders.

Results: Median age was 71 years, 49% were female, median Glasgow Coma Scale score was 12, median ICH volume was 13 cm(3), and 35% had early DNR orders. Overall observed 30-day mortality was 42.7% (95% confidence interval [CI] 38.3-47.1), with the average model-predicted 30-day mortality for the ICH Score, Cincinnati model, and ICH-GS at 39.9% (p = 0.005), 40.4% (p = 0.007), and 53.9% (p < 0.001). However, for patients with early DNR orders, the observed 30-day mortality was 83.5% (95% CI 78.0-89.1), with the models predicting mortality of 64.8% (p < 0.001), 57.2% (p < 0.001), and 77.8% (p = 0.02). For patients without early DNR orders, the observed 30-day mortality was 20.8% (95% CI 16.5-25.7), with the models predicting mortality of 26.6% (p = 0.05), 31.4% (p < 0.001), and 41.1% (p < 0.001).

Conclusions: ICH prognostic model performance is substantially impacted when stratifying by early DNR status, possibly giving a false sense of model accuracy when DNR status is not considered. Clinicians should be cautious when applying these predictive models to individual patients.

Publication types

  • Research Support, N.I.H., Extramural
  • Research Support, Non-U.S. Gov't
  • Research Support, U.S. Gov't, P.H.S.

MeSH terms

  • Aged
  • Aged, 80 and over
  • Cerebral Hemorrhage / epidemiology
  • Cerebral Hemorrhage / mortality*
  • Cerebral Hemorrhage / physiopathology
  • Cerebral Hemorrhage / therapy*
  • Chi-Square Distribution
  • Cohort Studies
  • Female
  • Hospital Mortality
  • Humans
  • Male
  • Middle Aged
  • Models, Statistical*
  • Predictive Value of Tests
  • ROC Curve
  • Resuscitation Orders*
  • Retrospective Studies
  • Severity of Illness Index