These consortia were formed in recognition that widespread implementation of do-not-resuscitate (DNR) orders requires systematic national and institutional policies. Their members are neurologists whose clinical practice and research projects focus on patients with acute stroke. These physicians are therefore involved in making decisions about DNR orders every day. To avoid inconsistency in the use of DNR orders, a specific definition of futility must be used.[1,2] However, general DNR policies[3] do not address issues particular to different conditions. Considerations affecting the use of DNR orders differ depending on whether patients have metastatic cancer, congestive heart failure or stroke. Therefore, members of the consortia decided to develop disease-specific guidelines for DNR decision making in cases of acute stroke.
The mortality rate is 15% during the first 15 days after a stroke,[4] and DNR orders are commonplace during the hospital stay of patients with stroke. The use of these orders is determined mainly by the severity of the stroke and the patient's cognitive impairment and age.[5] Since acute stroke is often unexpected and devastating, one study showed that only 8% of consecutive patients for whom DNR orders were written had discussed resuscitation as an option, and few had advance directives in place upon admission.[5] For a further 8% of incompetent patients, a DNR order had to be written unilaterally because no relatives of the patient were available.[5] As this study shows, firm prognostic criteria are needed to provide rational grounds for DNR decision making and discussions with patients and family.[6] To aid clinicians who deal with acute stroke, disease-specific criteria were developed as a supplement to general DNR policies.[5]
The Canadian and western New York neurologists were surveyed concerning their opinions on the proposed disease-specific criteria for DNR orders.[7] The definitions of severe stroke, life-threatening brain damage and significant comorbidities were detailed. If any two of these three conditions are present, there is an increased risk of death during the first 2 weeks after a stroke; this increased risk triggers a decision concerning DNR orders.[7] However, despite the agreement achieved,[7] the study also revealed shortcomings in existing data. "Grey areas" include the outcome of cardiopulmonary resuscitation in acute stroke, indications for mechanical ventilation and reliable predictors of death in patients with stroke who are not comatose on admission. Prospective, carefully designed outcome studies in this field would be of great importance, since effective tissue rescue measures are emerging,[8] and brain resuscitation is advocated.[9]
Caring for patients with acute stroke requires the efforts of a multidisciplinary team that includes neurologists, neurosurgeons, intensive care specialists, general practitioners and others. Ethical questions arise often, and the involvement of a clinical ethics consultant may be considered.[10] Avoiding resuscitation is appropriate when death is inevitable and patients almost certainly will not benefit from the procedure.[11] Although we are still some distance from determining firm prognostic factors in acute stroke, the first step toward informed decision making has been taken.[6,7]
Andrei V. Alexandrov, MD
Division of Neurology
University of Toronto
Toronto, Ont.
Eric M. Meslin, PhD
Clinical Ethics Centre
Sunnybrook Health Science Centre
North York, Ont.
Joint Centre for Bioethics
University of Toronto
Toronto, Ont.
References