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Early care limitations independently predict mortality after intracerebral hemorrhage

From the Stroke Program (D.B.Z., D.L.B., L.D.L., M.A.S., N.M.G., L.B.M.), University of Michigan Medical School, Ann Arbor; Department of Epidemiology (L.D.L., L.B.M.), University of Michigan School of Public Health, Ann Arbor; Stroke Program (N.R.G.), University of Texas Medical School at Houston; and practicing neurologist (P.J.L.), Corpus Christi, TX.

Address correspondence and reprint requests to Dr. Lewis B. Morgenstern, University of Michigan Medical School, 1500 East Medical Center Drive, TC 1920/0316, Ann Arbor, MI 48109-0316 LMorgens{at}umich.edu.

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.

Editorial, see page 1647.

Disclosure: This study was funded by NIH RO1 NS38916 and American Heart Association Postdoctoral Fellowship 0625692Z. Dr. Morgenstern has received one time consulting fees from Merck, and has given expert testimony on the topic of intracerebral hemorrhage. Dr. Gonzales has received consulting fees from NovoNordisk. The remaining authors report no conflicts of interest.

Received December 18, 2006. Accepted in final form February 12, 2007.

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