title: Process of care and mortality of stroke patients with and without a do not resuscitate order in the West Midlands, UK.
abstract: OBJECTIVE
  . To compare the process of care of stroke patients with and without a do not resuscitate (DNR) order.
  
  
  METHODS
  Retrospective case note review with prospective follow up of mortality.
  
  
  METHODS
  Seven acute hospitals, with stroke units, in the West Midlands, UK.
  
  
  METHODS
  A random sample of patients (n = 702) admitted to hospital with acute stroke over a twelve month period.
  
  
  METHODS
  Case mix and process of care measures derived from the intercollegiate stroke audit package. Thirty day and one year mortality.
  
  
  RESULTS
  About one-third (34%, 238/702) of stroke patients had DNR orders. The thirty-day mortality for DNR patients was 67% (160/238) versus 10% (46/449) for patients without DNR orders. DNR patients had significantly worse case-mix profile than non-DNR patients - median age 81 y vs 75y; fully conscious 36% vs 79%, able to walk 1% vs 21% and no loss of power in either arm 5% vs 24% (all p < 0.0001). DNR patients were more likely to be assessed early by a speech and language therapist (77% vs 59%, p < 0.001), but less likely to receive the majority of their care in a stroke/rehabilitation unit (20% vs 57%, p < 0.0001), or be cared for on a stroke unit or by a stroke team (42% vs 70%, p <0.0001), or had a description of the site of the cerebral lesion (31% vs 38%, p = 0.05) or be given aspirin (30% vs 42%, p = 0.007).
  
  
  CONCLUSIONS
  Stroke patients with a DNR order are not receiving optimum care in that they are not being cared for on stroke units or by specialist teams. This may reflect the inadequate provision of specialist stroke services in the UK.
authors.affiliation: Public Health & Epidemioogy, Birmingham University, Birmingham, UK. m.a.mohammed@bham.ac.uk
authors.forename: Mohammed A
authors.initials: MA
authors.lastname: Mohammed
authors.forename: Jonathan
authors.initials: J
authors.lastname: Mant
authors.forename: Louise
authors.initials: L
authors.lastname: Bentham
authors.forename: Andrew
authors.initials: A
authors.lastname: Stevens
authors.forename: Shakir
authors.initials: S
authors.lastname: Hussain
mesh_terms: D000367:Age Factors; D000368:Aged; D000369:Aged, 80 and over; D003953:Diagnosis-Related Groups; D004739:England / Q000453:epidemiology; D006297:Health Services Accessibility; D006779:Hospitals, Public / Q000592:standards; D006801:Humans; D007362:Intensive Care Units / Q000592:standards* / Q000706:statistics & numerical data; D016015:Logistic Models; D008485:Medical Audit; D010043:Outcome and Process Assessment, Health Care; D010348:Patient Care Team / Q000592:standards; D010814:Physical Therapy Department, Hospital / Q000592:standards / Q000706:statistics & numerical data; D016414:Resuscitation Orders; D020521:Stroke / Q000145:classification / Q000401:mortality*; D000071939:Stroke Rehabilitation; D014218:Triage