Sex Differences in the Use of Early Do-Not-Resuscitate Orders After Intracerebral Hemorrhage
Background and Purpose—Studies show that women are more likely to receive do-not-resuscitate (DNR) orders after acute medical illnesses than men. However, the sex differences in the use of DNR orders after acute intracerebral hemorrhage (ICH) have not been described.
Methods—We conducted a retrospective study of consecutive patients hospitalized for acute ICH at a tertiary stroke center between 2006 and 2010. Unadjusted and multivariable logistic regression analyses were performed to test for associations between female sex and early (<24 hours of presentation) DNR orders.
Results—A total of 372 consecutive ICH patients without preexisting DNR orders were studied. Overall, 82 (22%) patients had early DNR orders after being hospitalized with ICH. In the fully adjusted model, early DNR orders were more likely in women (odds ratio, 3.18; 95% confidence interval, 1.51–6.70), higher age (odds ratio, 1.09 per year; 95% confidence interval, 1.05–1.12), larger ICH volume (odds ratio, 1.01 per cm3; 95% confidence interval, 1.01–1.02), and lower initial GCS score (odds ratio, 0.76 per point; 95% confidence interval, 0.69–0.84). Early DNR orders were less likely when the patients were transferred from another hospital (odds ratio, 0.28, 95% confidence interval, 0.11–0.76).
Conclusions—Women are more likely to receive early DNR orders after ICH than men. Further prospective studies are needed to determine factors contributing to the sex variation in the use of early DNR order after ICH.
The use of early (<24 hours from presentation) do-not-resuscitate (DNR) orders after intracerebral hemorrhage (ICH) has been regarded as a form of care limitation1–4 or a proxy for lack of overall aggressiveness of care.1,2,4 Previous studies assessing the use of DNR orders in the inpatient settings suggest that women are more likely to receive DNR orders than men after various medical illnesses.3,5–7 However, the sex differences in the use of early DNR orders specific to ICH patients have not been studied.
We conducted a retrospective study of all spontaneous ICH patients hospitalized at a tertiary stroke center in Honolulu, Oahu, between January 1, 2006, and August 31, 2010, to assess sex differences in the use of early DNR orders after ICH. The DNR orders were defined as any plan to limit cardiopulmonary resuscitation in the event of a cardiopulmonary arrest. Preexisting DNR was determined if the electronic medical record before admission or the advance directive specified the preexisting DNR status. Early DNR (within 24 hours of presentation) was based on the date/time of the DNR order entry relative to the date/time of patient arrival. The data on withdrawal of life support were also collected.
Multivariable analyses using a logistic regression model were performed using SPSS, version 20.0 (Chicago, IL), to identify factors associated with early DNR orders. All covariates for the models were preselected based on biological plausibility, and included sex, age, initial Glasgow Coma Scale (GCS) score, ICH volume, intraventricular hemorrhage, infratentorial hemorrhage, admitting team, and whether they were transferred from another hospital. The analysis of time to DNR decision-making over a 30-day period was performed by Kaplan–Meier survival analysis.
A total of 396 consecutive ICH patients with validated spontaneous ICH were identified. Twenty-four patients with preexisting DNR orders (6 of 218 men [3%] versus 18 of 178 women [10%; P=0.002]) were excluded. A total of 372 ICH patients without preexisting DNR orders were included for the final analysis. Demographic and baseline characteristics of those with and without early DNR orders are presented in the Table. The comparison of clinical characteristics between men and women showed that women were older (66±17 versus 61±16 years of age; P=0.01) and less likely to smoke (8% versus 22%; P<0.0001) than men. Furthermore, women were more likely to be admitted to the floor for comfort care compared with men (13% versus 4%; P=0.003). There was a trend toward less ICU admission among women compared with men (54% versus 63%; P=0.07).
Unadjusted analysis of early DNR orders showed that women were more likely to receive an early DNR order compared with men (OR, 2.24; 95% CI, 1.36–3.70). Multivariable analysis showed that early DNR orders were more likely in women (OR, 3.18; 95% CI, 1.51–6.70). Higher age (OR, 1.09 per year; 95% CI, 1.05–1.12), larger ICH volume (OR, 1.01 per cm3; 95% CI, 1.01–1.02), and lower initial GCS score (OR, 0.76 per point; 95% CI, 0.69–0.84) were also independently associated with early DNR orders. Early DNR orders were less likely when the patients were transferred from another hospital (OR, 0.28; 95% 0.11–0.76). Kaplan–Meier curves showed a significant difference in the time to DNR between the two sexes (Figure 1).
The proportion of ICH patients with early DNR orders, based on the ICH Score, is shown in Figure 2. Even among the patients with a less severe ICH Score of 0 to 3 (n=326), women had a higher prevalence of early DNR orders than men (21% versus 12%; P=0.03). Despite these differences in the prevalence of early DNR orders, the discharge mortality (26% versus 26%; P=0.87) and the withdrawal of life support rate (23% versus 18%; P=0.23) were not different between women and men.
Our study showed that women with ICH are more likely to receive early DNR orders, independent of age and clinical severity, compared with men with ICH. Our results are similar to previous studies that showed sex differences in the use of DNR orders among patients with other acute medical illnesses5–7 and support the idea that women seek less heroic resuscitative measures on cardiopulmonary arrest compared with men.
Because many ICH patients are unable to make important end-of-life decisions as a result of their neurological impairment, the decision to initiate a DNR order within 24 hours of admission for those without preexisting DNR orders, for the most part, reflects the dialogue of aggressiveness of care between the families and the clinicians. It may be that women, compared with men, are more likely to have already expressed their wishes to the families/surrogate decision-makers and more explicitly advised them how to handle such a situation, making it easier for the families to decide on the DNR status (no heroic resuscitative measures) early in the hospital course. These explanations are supported by the higher prevalence of preexisting DNR orders, higher rate of comfort care on admission, and a trend toward less ICU admission among women compared with men.
Female sex is independently associated with the use of early DNR orders after ICH. Further prospective studies are needed to determine factors contributing to the sex variation in the use of early DNR orders and end-of-life discussion after ICH.
Sources of Funding
Dr Nakagawa was supported in part by the American Heart Association (11CRP7160019) and the National Institute on Minority Health and Health Disparities (P20MD000173). Dr Seto was supported in part by the National Institute on Minority Health and Health Disparities (U54MD007584). Dr Hemphill was supported in part by the National Institute of Neurological Disorders and Stroke (U10NS058931).
- Received July 13, 2013.
- Accepted July 17, 2013.
- © 2013 American Heart Association, Inc.