Hospital usage of early do-not-resuscitate orders and outcome after intracerebral hemorrhage

Background and Purpose - Do-not-resuscitate (DNR) orders are commonly used after severe stroke. We hypothesized that there is significant variability in how these orders are applied after intracerebral hemorrhage and that this influences outcome. Methods - From a database of all admissions to nonfederal hospitals in California, discharge abstracts were obtained for all patients with a primary diagnosis of intracerebral hemorrhage who were admitted through the emergency department during 1999 and 2000. Characteristics included whether DNR orders were written within the first 24 hours of hospitalization. Case-mix-adjusted hospital DNR use was calculated for each hospital by comparing the actual number of DNR cases with the number predicted from a multivariable model. Outcome (in-hospital death) was evaluated in a separate multivariable model adjusted for individual and hospital characteristics. Results - A total of 8233 patients were treated in 234 hospitals. The percentage of patients with DNR orders varied from 0% to 70% across hospitals. Being treated in a hospital that used DNR orders 10% more often than another hospital with a similar case mix increased a patient's odds of dying during hospitalization by 13% (P < 0.001). Patients treated in the quartile of hospitals with the highest adjusted DNR use were more likely to die, and this was not just because of individual patient DNR status. Conclusions - In-hospital mortality after intracerebral hemorrhage is significantly influenced by the rate at which treating hospitals use DNR orders, even after adjusting for case mix. This is not due solely to individual patient DNR status, but rather some other aspect of overall care.