Process of care and mortality of stroke patients with and without a do-not-resuscitate order in the West Midlands UK

Objectives. To compare the process of care of stroke patients with and without a do not resuscitate (DNR) order. Design. Retrospective case note review with prospective follow up of mortality. Setting. Seven acute hospitals, with stroke units, in the West Midlands, UK. Participants. A random sample of patients (n = 702) admitted to hospital with acute stroke over a twelve month period. Main outcome measures. Case mix and process of care measures derived from the intercollegiate stroke audit package. Thirty day and one year mortality. Results. About one-third (34%, 238/702) of stroke patients had DNR orders. The thirty-day mortality for DNR patients was 67% (160/238) versus 10% (46/449) for patients without DNR orders. DNR patients had significantly worse case-mix profile than non-DNR patients-median age 81 y vs 75y; fully conscious 36% vs 79%, able to walk 1% vs 21% and no loss of power in either arm 5% vs 24% (all p <0.0001). DNR patients were more likely to be assessed early by a speech and language therapist (77% vs 59%, p <0.001), but less likely to receive the majority of their care in a stroke/rehabilitation unit (20% vs 57%, p <0.0001), or be cared for on a stroke unit or by a stroke team (42% vs 70%, p <0.0001), or had a description of the site of the cerebral lesion (31% vs 38%, p = 0.05) or be given aspirin (30% vs 42%, p = 0.007). Conclusions. Stroke patients with a DNR order are not receiving optimum care in that they are not being cared for on stroke units or by specialist teams. This may reflect the inadequate provision of specialist stroke services in the UK.