Do-not-resuscitate orders and predictive models after intracerebral hemorrhage

Abstract

Objective: To quantify the accuracy of commonly used intracerebral hemorrhage (ICH) predictive models in ICH patients with and without early do-not-resuscitate orders (DNR).

Methods: Spontaneous ICH cases (n = 487) from the Brain Attack Surveillance in Corpus Christi study (2000-2003) and the University of California, San Francisco (June 2001-May 2004) were included. Three models (the ICH Score, the Cincinnati model, and the ICH grading scale [ICH-GS]) were compared to observed 30-day mortality with a chi(2) goodness-of-fit test first overall and then stratified by early DNR orders.

Results: Median age was 71 years, 49% were female, median Glasgow Coma Scale score was 12, median ICH volume was 13 cm(3), and 35% had early DNR orders. Overall observed 30-day mortality was 42.7% (95% confidence interval [CI] 38.3-47.1), with the average model-predicted 30-day mortality for the ICH Score, Cincinnati model, and ICH-GS at 39.9% (p = 0.005), 40.4% (p = 0.007), and 53.9% (p < 0.001). However, for patients with early DNR orders, the observed 30-day mortality was 83.5% (95% CI 78.0-89.1), with the models predicting mortality of 64.8% (p < 0.001), 57.2% (p < 0.001), and 77.8% (p = 0.02). For patients without early DNR orders, the observed 30-day mortality was 20.8% (95% CI 16.5-25.7), with the models predicting mortality of 26.6% (p = 0.05), 31.4% (p < 0.001), and 41.1% (p < 0.001).

Conclusions: ICH prognostic model performance is substantially impacted when stratifying by early DNR status, possibly giving a false sense of model accuracy when DNR status is not considered. Clinicians should be cautious when applying these predictive models to individual patients.

Figure 1 Comparison of observed and predicted mortality for the intracerebral hemorrhage (ICH) Score Comparison of ICH Score predicted 30-day mortality with actual observed mortality for (A) the overall cohort, (B) patients with early do-not-resuscitate (DNR) orders, and (C) patients without early DNR orders. Note that the predicted mortality for an ICH Score of 0 is 0%, and therefore there is no solid black bar shown for an ICH Score of 0. Error bars represent the standard error.

Figure 2 Comparison of observed and predicted mortality for the Cincinnati model Comparison of Cincinnati model–predicted 30-day mortality with actual observed mortality for (A) the overall cohort, (B) patients with early do-not-resuscitate (DNR) orders, and (C) patients without early DNR orders. Predicted mortality categories of 44% and 46% and 74% and 75% were pooled for the graph and for the primary analysis. Error bars represent the standard error.

Figure 3 Comparison of observed and predicted mortality for the intracerebral hemorrhage (ICH) grading scale (ICH-GS) Comparison of ICH-GS–predicted 30-day mortality with actual observed mortality for (A) the overall cohort, (B) patients with early do-not-resuscitate (DNR) orders, and (C) patients without early DNR orders. No patients had an ICH-GS of 13. Only 4 patients had an ICH-GS of 5 (all survived to 30 days) and are not shown in the figure. One patient with early DNR orders had an ICH-GS of 6 (deceased) and is not shown in B. Error bars represent the standard error.