title: Early care limitations independently predict mortality after intracerebral hemorrhage.
abstract: 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.
authors.affiliation: Stroke Program, University of Michigan Medical School, Ann Arbor, MI 48109-0316, USA.
authors.forename: D B
authors.initials: DB
authors.lastname: Zahuranec
authors.forename: D L
authors.initials: DL
authors.lastname: Brown
authors.forename: L D
authors.initials: LD
authors.lastname: Lisabeth
authors.forename: N R
authors.initials: NR
authors.lastname: Gonzales
authors.forename: P J
authors.initials: PJ
authors.lastname: Longwell
authors.forename: M A
authors.initials: MA
authors.lastname: Smith
authors.forename: N M
authors.initials: NM
authors.lastname: Garcia
authors.forename: L B
authors.initials: LB
authors.lastname: Morgenstern
mesh_terms: D000367:Age Factors; D000368:Aged; D000369:Aged, 80 and over; D001291:Attitude of Health Personnel; D001925:Brain Damage, Chronic / Q000517:prevention & control / Q000523:psychology; D002423:Cause of Death; D002543:Cerebral Hemorrhage / Q000150:complications / Q000401:mortality* / Q000523:psychology; D003128:Coma / Q000209:etiology; D015897:Comorbidity; D015986:Confounding Factors, Epidemiologic; D003399:Craniotomy / Q000706:statistics & numerical data; D004322:Drainage / Q000706:statistics & numerical data; D005190:Family; D005260:Female; D005500:Follow-Up Studies; D006406:Hematoma / Q000209:etiology / Q000601:surgery; D017052:Hospital Mortality; D006764:Hospitals, Community / Q000706:statistics & numerical data; D006801:Humans; D006849:Hydrocephalus / Q000209:etiology / Q000601:surgery; D053208:Kaplan-Meier Estimate; D008297:Male; D008875:Middle Aged; D009735:Nursing Homes; D011379:Prognosis; D016016:Proportional Hazards Models; D016414:Resuscitation Orders / Q000941:ethics; D012189:Retrospective Studies; D012306:Risk; D012307:Risk Factors; D016019:Survival Analysis; D013727:Terminal Care / Q000941:ethics / Q000706:statistics & numerical data*; D013781:Texas / Q000453:epidemiology; D013997:Time Factors; D016896:Treatment Outcome; D014696:Ventriculostomy / Q000706:statistics & numerical data; D028761:Withholding Treatment / Q000941:ethics / Q000706:statistics & numerical data