Original Paper Eur Neurol 2015;73:144–149 DOI: 10.1159/000369792
Received: July 10, 2014 Accepted: November 9, 2014 Published online: January 6, 2015
Do Not Resuscitate Orders for Patients with Intracerebral Hemorrhage: Experience from a Chinese Tertiary Care Center Tie-Cheng Yang Jian-Guo Li Wei Guo Emergency Department, Beijing Tiantan Hospital, Capital Medical University/Beijing Neurosurgical Institute, China National Clinical Research Center for Neurological Diseases, Center of Stroke, Beijing Institute for Brain Disorders/Beijing Key Laboratory of Translational Medicine for Cerebrovascular Disease, Beijing, China
Key Words Do not resuscitate · Intracerebral hemorrhage · Prognosis · Mortality
Abstract Aim: This study aimed to determine the frequency and determinant factors of do not resuscitate (DNR) orders in patients with intracerebral hemorrhage (ICH) at a university hospital in China. Methods: Data collected from June 2010 to December 2012 for patients with ICH were retrospectively reviewed. The characteristics and care of patients with and without DNR orders and those with early (≤24 h) and late (>24 h) DNR establishment were compared. Results: Formal DNR orders were filed during hospitalization for 64/759 (8.4%) patients with complete medical records enrolled in this study. Patients with DNR orders were older on average (73.1 ± 10.1 vs. 56.0 ± 13.2 years; p < 0.001) and a larger proportion had pre-ICH comorbidity impacting dependency (87.5 vs. 17.0%; p < 0.001) than did those with no DNR order. Patients with DNR orders were in worse clinical condition on arrival than those without a DNR order, as judged by Glasgow Coma Scale scores, and more frequently had large hematoma volumes (78.1 vs. 39.7%; p < 0.001). Conclusions: DNR orders were not used commonly for patients with ICH in this Chinese sample. No relationship between ICH severity and DNR decision making was observed. © 2015 S. Karger AG, Basel
© 2015 S. Karger AG, Basel 0014–3022/15/0734–0144$39.50/0 E-Mail [email protected] www.karger.com/ene
Introduction
Intracerebral hemorrhage (ICH) is a serious disease with reported 30-day case fatality rates as high as 40–50% [1, 2]. This disease causes substantial disability in survivors, with only 20% of patients expected to be functionally independent at 6 months after the event [3]. Given this poor prognosis, physicians who receive patients with acute ICH may have questions about the level-of-care decisions, as they wish to avoid exposing patients to unnecessary suffering. Do not resuscitate (DNR) orders are designed to limit the use of cardiopulmonary resuscitation in patients with limited prognosis or poor quality of life. Besides the underlying disease characteristics, DNR orders also involve many complicated factors, such as religious or cultural beliefs and socioeconomic status. Moreover, large differences exist among hospitals and countries in practices related to DNR orders [4, 5]. Several studies have found that many patients with ICH prepare DNR orders, and that the establishment of these orders on the first day of hospitalization is an independent predictor of poor outcome in these patients [4– 6]. However, these studies were conducted in American
T.-C.Y. and J.-G.L. contributed equally to this work and should be considered co-first authors.
Wei Guo Emergency Department, Beijing Tiantan Hospital, Capital Medical University/Beijing Neurosurgical Institute, China National Clinical, Research Center for Neurological Diseases, Center of Stroke, Beijing Institute for Brain Disorders/Beijing Key, Laboratory of Translational Medicine for Cerebrovascular Disease, Beijing 100050 (China) E-Mail guowei1942 @ sina.com
and European countries. No report has described DNR usage in patients experiencing hemorrhagic stroke in Asia. In this study, we aimed to determine the frequency and determinant factors of DNR orders in patients with ICH at a university hospital in China. The effect of DNR orders on the care of these patients was also evaluated.
Materials and Methods This study was conducted at the Affiliated Hospital of Capital Medical University, Beijing, China. Written informed consent was obtained from patients or family members and the study was approved by Research Ethic Committee in Beijing Tiantan Hospital, Capital Medical University (Beijing, China). This hospital has one of the largest neurology departments in China, with about 1,000 stroke patient admissions annually. Data on patients with ICH collected from June 2010 to December 2012 were retrospectively reviewed. ICH was defined as a neurological deficit with brain hemorrhage confirmed by computed tomography (CT) [3]. Patients with hemorrhage secondary to brain tumors, trauma, hemorrhagic transformation of cerebral infarction, or aneurysmal or vascular malformation rupture were excluded from the study. Two independent physicians reviewed all available medical and nursing records from patients with ICH. Demographic and clinical data were collected, including patients’ age, sex, medical history, initial Glasgow Coma Scale (GCS) score, head CT findings, length of hospitalization, and in-hospital death. Pre-ICH comorbidity (malignancy, heart and/or lung disease, or other severe disease impacting dependency and daily activities) was recorded. Data on in-hospital care for ICH [i.e., repeat imaging examinations, external ventricular drain (EVD) placement, surgical hematoma evacuation, intubation, mechanical ventilation, medication] were also collected. Initial CT examinations were used to characterize neuroradiological findings. The location (supratentorial or infratentorial) and volume of hematoma and intraventricular hemorrhage (IVH) were noted. The volume of hematoma was determined using the ABC/2 method [7], in which A refers to the greatest diameter of the largest hemorrhage slice, B denotes the diameter perpendicular to A, and C is the approximate number of axial slices with hemorrhage multiplied by slice thickness. Information about DNR orders was also retrieved from patient records. A DNR order was defined as an order included in the medical records and signed by a family member to limit cardiopulmonary resuscitation, intubation, and mechanical ventilation in the event of a cardiac or respiratory arrest. These orders were categorized as early (≤24 h after admission) or late (>24 h after admission).
Binary logistic regression analysis was conducted to identify factors associated independently with the decision to establish a DNR order, with the presence of a DNR order serving as the dependent variable and all other baseline factors (age, sex, pre-ICH comorbidity, GCS score, ICH volume, location of hematoma and IVH) serving as independent variables. A p value 24 h) DNR establishment were compared. For univariate analysis, the unpaired t-test was used to compare continuous variables, chi-squared analysis and contingency tables were used to compare nominal and dichotomous variables, and the Mann-Whitney rank sum test was used for ordinal variables.
Data from 825 consecutive patients admitted to our hospital with ICH between June 2010 to December 2012 were reviewed; 759 patients for whom complete medical records were available were enrolled in the study. Formal DNR orders were filed for 64/759 (8.4%) patients during hospitalization. The baseline characteristics of the study sample are provided in table 1. In comparison with non-DNR patients, those with DNR orders were significantly older on average and a large proportion had pre-ICH comorbidity impacting dependency. Patients with DNR orders were also in a worse clinical condition on arrival than those who were with no DNR order, as judged by GCS scores. Large hematoma volumes and IVH were seen more frequently in patients with DNR orders than in those without DNR orders (all p < 0.001; table 1). The location of ICH did not differ significantly between groups. Several aspects of treatment differed significantly between patients with and without DNR orders. A large proportion of patients with DNR orders than without DNR orders received intensive care unit (ICU) care, but fewer patients with DNR orders received intubation or mechanical ventilation, and none underwent craniotomy or EVD placement (all p < 0.001; table 2). More patients with DNR orders than without them received mannitol (p < 0.05; table 2). The use of other treatments did not differ significantly between groups. The in-hospital mortality rate was higher and the length of hospitalization was much shorter in patients with DNR orders than in those without them (both p < 0.001; table 2). Multivariate logistic regression demonstrated that older age and pre-ICH comorbidity were independently associated with the decision to establish a DNR order (table 3). The majority of DNR orders were issued >24 h after admission. Comparison of the early and late DNR groups revealed no significant difference in baseline characteristics or outcome (table 4). Repeat imaging examinations were performed in fewer patients with early than with late DNR establishment (p < 0.001), but no other difference in interventional care was noted.
Care Limitations in Intracerebral Hemorrhage
Eur Neurol 2015;73:144–149 DOI: 10.1159/000369792
145
Table 1. Baseline characteristics of patients with ICH with and without DNR orders
Age, years (mean ± SD) Sex, % Male Female Pre-ICH comorbidity GCS score on arrival, %
Received: July 10, 2014 Accepted: November 9, 2014 Published online: January 6, 2015
Do Not Resuscitate Orders for Patients with Intracerebral Hemorrhage: Experience from a Chinese Tertiary Care Center Tie-Cheng Yang Jian-Guo Li Wei Guo Emergency Department, Beijing Tiantan Hospital, Capital Medical University/Beijing Neurosurgical Institute, China National Clinical Research Center for Neurological Diseases, Center of Stroke, Beijing Institute for Brain Disorders/Beijing Key Laboratory of Translational Medicine for Cerebrovascular Disease, Beijing, China
Key Words Do not resuscitate · Intracerebral hemorrhage · Prognosis · Mortality
Abstract Aim: This study aimed to determine the frequency and determinant factors of do not resuscitate (DNR) orders in patients with intracerebral hemorrhage (ICH) at a university hospital in China. Methods: Data collected from June 2010 to December 2012 for patients with ICH were retrospectively reviewed. The characteristics and care of patients with and without DNR orders and those with early (≤24 h) and late (>24 h) DNR establishment were compared. Results: Formal DNR orders were filed during hospitalization for 64/759 (8.4%) patients with complete medical records enrolled in this study. Patients with DNR orders were older on average (73.1 ± 10.1 vs. 56.0 ± 13.2 years; p < 0.001) and a larger proportion had pre-ICH comorbidity impacting dependency (87.5 vs. 17.0%; p < 0.001) than did those with no DNR order. Patients with DNR orders were in worse clinical condition on arrival than those without a DNR order, as judged by Glasgow Coma Scale scores, and more frequently had large hematoma volumes (78.1 vs. 39.7%; p < 0.001). Conclusions: DNR orders were not used commonly for patients with ICH in this Chinese sample. No relationship between ICH severity and DNR decision making was observed. © 2015 S. Karger AG, Basel
© 2015 S. Karger AG, Basel 0014–3022/15/0734–0144$39.50/0 E-Mail [email protected] www.karger.com/ene
Introduction
Intracerebral hemorrhage (ICH) is a serious disease with reported 30-day case fatality rates as high as 40–50% [1, 2]. This disease causes substantial disability in survivors, with only 20% of patients expected to be functionally independent at 6 months after the event [3]. Given this poor prognosis, physicians who receive patients with acute ICH may have questions about the level-of-care decisions, as they wish to avoid exposing patients to unnecessary suffering. Do not resuscitate (DNR) orders are designed to limit the use of cardiopulmonary resuscitation in patients with limited prognosis or poor quality of life. Besides the underlying disease characteristics, DNR orders also involve many complicated factors, such as religious or cultural beliefs and socioeconomic status. Moreover, large differences exist among hospitals and countries in practices related to DNR orders [4, 5]. Several studies have found that many patients with ICH prepare DNR orders, and that the establishment of these orders on the first day of hospitalization is an independent predictor of poor outcome in these patients [4– 6]. However, these studies were conducted in American
T.-C.Y. and J.-G.L. contributed equally to this work and should be considered co-first authors.
Wei Guo Emergency Department, Beijing Tiantan Hospital, Capital Medical University/Beijing Neurosurgical Institute, China National Clinical, Research Center for Neurological Diseases, Center of Stroke, Beijing Institute for Brain Disorders/Beijing Key, Laboratory of Translational Medicine for Cerebrovascular Disease, Beijing 100050 (China) E-Mail guowei1942 @ sina.com
and European countries. No report has described DNR usage in patients experiencing hemorrhagic stroke in Asia. In this study, we aimed to determine the frequency and determinant factors of DNR orders in patients with ICH at a university hospital in China. The effect of DNR orders on the care of these patients was also evaluated.
Materials and Methods This study was conducted at the Affiliated Hospital of Capital Medical University, Beijing, China. Written informed consent was obtained from patients or family members and the study was approved by Research Ethic Committee in Beijing Tiantan Hospital, Capital Medical University (Beijing, China). This hospital has one of the largest neurology departments in China, with about 1,000 stroke patient admissions annually. Data on patients with ICH collected from June 2010 to December 2012 were retrospectively reviewed. ICH was defined as a neurological deficit with brain hemorrhage confirmed by computed tomography (CT) [3]. Patients with hemorrhage secondary to brain tumors, trauma, hemorrhagic transformation of cerebral infarction, or aneurysmal or vascular malformation rupture were excluded from the study. Two independent physicians reviewed all available medical and nursing records from patients with ICH. Demographic and clinical data were collected, including patients’ age, sex, medical history, initial Glasgow Coma Scale (GCS) score, head CT findings, length of hospitalization, and in-hospital death. Pre-ICH comorbidity (malignancy, heart and/or lung disease, or other severe disease impacting dependency and daily activities) was recorded. Data on in-hospital care for ICH [i.e., repeat imaging examinations, external ventricular drain (EVD) placement, surgical hematoma evacuation, intubation, mechanical ventilation, medication] were also collected. Initial CT examinations were used to characterize neuroradiological findings. The location (supratentorial or infratentorial) and volume of hematoma and intraventricular hemorrhage (IVH) were noted. The volume of hematoma was determined using the ABC/2 method [7], in which A refers to the greatest diameter of the largest hemorrhage slice, B denotes the diameter perpendicular to A, and C is the approximate number of axial slices with hemorrhage multiplied by slice thickness. Information about DNR orders was also retrieved from patient records. A DNR order was defined as an order included in the medical records and signed by a family member to limit cardiopulmonary resuscitation, intubation, and mechanical ventilation in the event of a cardiac or respiratory arrest. These orders were categorized as early (≤24 h after admission) or late (>24 h after admission).
Binary logistic regression analysis was conducted to identify factors associated independently with the decision to establish a DNR order, with the presence of a DNR order serving as the dependent variable and all other baseline factors (age, sex, pre-ICH comorbidity, GCS score, ICH volume, location of hematoma and IVH) serving as independent variables. A p value 24 h) DNR establishment were compared. For univariate analysis, the unpaired t-test was used to compare continuous variables, chi-squared analysis and contingency tables were used to compare nominal and dichotomous variables, and the Mann-Whitney rank sum test was used for ordinal variables.
Data from 825 consecutive patients admitted to our hospital with ICH between June 2010 to December 2012 were reviewed; 759 patients for whom complete medical records were available were enrolled in the study. Formal DNR orders were filed for 64/759 (8.4%) patients during hospitalization. The baseline characteristics of the study sample are provided in table 1. In comparison with non-DNR patients, those with DNR orders were significantly older on average and a large proportion had pre-ICH comorbidity impacting dependency. Patients with DNR orders were also in a worse clinical condition on arrival than those who were with no DNR order, as judged by GCS scores. Large hematoma volumes and IVH were seen more frequently in patients with DNR orders than in those without DNR orders (all p < 0.001; table 1). The location of ICH did not differ significantly between groups. Several aspects of treatment differed significantly between patients with and without DNR orders. A large proportion of patients with DNR orders than without DNR orders received intensive care unit (ICU) care, but fewer patients with DNR orders received intubation or mechanical ventilation, and none underwent craniotomy or EVD placement (all p < 0.001; table 2). More patients with DNR orders than without them received mannitol (p < 0.05; table 2). The use of other treatments did not differ significantly between groups. The in-hospital mortality rate was higher and the length of hospitalization was much shorter in patients with DNR orders than in those without them (both p < 0.001; table 2). Multivariate logistic regression demonstrated that older age and pre-ICH comorbidity were independently associated with the decision to establish a DNR order (table 3). The majority of DNR orders were issued >24 h after admission. Comparison of the early and late DNR groups revealed no significant difference in baseline characteristics or outcome (table 4). Repeat imaging examinations were performed in fewer patients with early than with late DNR establishment (p < 0.001), but no other difference in interventional care was noted.
Care Limitations in Intracerebral Hemorrhage
Eur Neurol 2015;73:144–149 DOI: 10.1159/000369792
145
Table 1. Baseline characteristics of patients with ICH with and without DNR orders
Age, years (mean ± SD) Sex, % Male Female Pre-ICH comorbidity GCS score on arrival, %
