Anusha Boyanpally, MD

Bailoor K, Shafie-Khorassani F, Lank RJ, Case E, Garcia NM, Lisabeth LD, et al. Time Trends in Race-Ethnic Differences in Do-Not-Resuscitate Orders After Stroke. Stroke. 2019;50:1641–1647.

In-hospital mortality was significantly influenced by Do-not-resuscitate (DNR) orders in patients with intracerebral hemorrhage (ICH) (1). In 2007, the American Heart Association/American Stroke Association updated guidelines to avoid early DNR orders in the first 24 hours after ICH admission (2).

This is a single center study with a large minority population, which assessed calendar time trends of DNR orders after stroke from 2007 through 2016 in the ischemic stroke (IS) and intracerebral hemorrhage (ICH) patients in different race-ethnic groups.

Only the first stroke events (both IS or ICH) were included, and patients with missing DNR status were excluded. Race-ethnicity was obtained both from medical records and from interview if missing from medical records. Time to DNR was calculated as time from stroke presentation to DNR order in hours. DNR orders were considered early if documented at or before 24 hours from the admission, and late if documented > 24 hours after admission. The authors have included neurodegenerative disease, history coronary artery disease, congestive heart failure, myocardial infarction, cancer, chronic obstructive pulmonary disease, end stage renal disease, cholesterol, hypertension, history of stroke, atrial fibrillation, diabetes, insurance status, and stroke severity. The authors initially used two types of 3-way interaction: one was between stroke type, calendar year, and binary DNR timing; another one was between race-ethnicity, calendar year, and DNR timing, but was removed due to lack of significance. So, eventually calculated 2-way interactions. DNR timing (early and late) was represented as dichotomous covariates.

From a total of 4967 cases, 2672 individuals were available for analysis after exclusion. Mean age was 69, Mexican Americans were 58%, non-Hispanics whites were 37%, and African Americans were 5%. Overall, 16% had DNR orders during hospitalization. Over the study period, for ICH: DNR orders for both early and late were stable; for IS: early DNR orders became more frequent over time (HR for 2016 vs 2017: 1.89; 95 CI, 1.06-3.39), but no change over time for late DNR. Mexican Americans and African Americans were less likely to have early DNR than Hispanic whites, but there was no race-ethnic difference in late DNR orders.

This study may not be generalizable because most of the study population were minority, and it was a single-center data, which were significant drawbacks in this study. There was no mention about the size of the ICH and if they had intraventricular extension of the hemorrhage, which affects the prognosis and the decision to opt for DNR status. Similarly, in ischemic strokes, the size of the infarct and the location of the infarct determines the prognosis, which were not included in the study. In patients with DNR status, age >80 was (52.7 %), history of prior stroke was seen in 134 (31.4%), neurodegenerative disease in 107 (25.1%), heart disease in 195 (45.7%) and cancer in 69 (16.2%) patients, which could have led to opt for DNR status. 57.6% of the patients had NIHSS 13-42, which suggests a big stroke leading to significant disability. Probably, calculating early and late DNR time from the time of stroke would have been better instead of time from admission. Mortality was not categorized as all-cause mortality or stroke-related deaths. Also, not sure whether deaths were calculated only while inpatient. Censored data was not clearly stated in the methods section.

The study has shown no change in the trends of early or late DNR in patients with ICH. On the other hand, surprisingly, there was a slight increase in early DNR orders after IS. The authors have used relatively better methods such as calculating agreement analysis between the medical record and self-reported race-ethnic group. They also used one sensitive analysis to address missing data for DNR whether it occurred randomly, and second sensitive analysis to assess the stability of the conclusions due to missing data in the 2014 study period. This paper discussed the possible reasons behind choosing early and late DNR orders. Explanations were not clear for why there was an increased trend in early DNR orders in the IS category despite advancement in developing new endovascular stroke treatments. Similarly, no clear reasons behind the increasing trend of early DNR orders in the non-Hispanic white population. Not sure whether non-Hispanic patients have higher comorbidity profile (no race-ethnicity based patient characteristics). Also, the African American population in this study was under-represented.    

In this paper, the authors have stated the appropriate existing knowledge gap in this area and had clear goals for this study. In spite of the 2007 AHA guidelines against early DNR orders in ICH patients, the study shows no change in early DNR after ICH from 2007 to 2016. Future research should be on exploring reasons for increased DNR in the IS category and race-ethnic differences.


1. Hemphill JC III, Newman J, Zhao S, Johnston SC. Hospital usage of early do-not-resuscitate orders and outcome after intracerebral hemorrhage. Stroke. 2004;35:1130–1134.

2. Broderick J, Connolly S, Feldmann E, Hanley D, Kase C, Krieger D, et al; American Heart Association; American Stroke Association Stroke Council; High Blood Pressure Research Council; Quality of Care and Outcomes in Research Interdisciplinary Working Group. Guidelines for the management of spontaneous intracerebral hemorrhage in adults: 2007 update: a guideline from the American Heart Association/American Stroke Association Stroke Council, High Blood Pressure Research Council, and the Quality of Care and Outcomes in Research Interdisciplinary Working Group. Stroke. 2007;38:2001–2023.