A DNR order
may be written any time that two
of the following clinical
criteria are present and the
prognosis has become clear for
and shared whenever possible
between physician(s), patient,
and family (or appropriate
surrogate).
1. Severe
Stroke
Clinically severe stroke
produces persisting (more than
24 hours) and sometimes
deteriorating neurological
deficit, often with early
impairment of consciousness
leading to total dependency of
the patient in activities of
daily living. The patient must
have little or no active
movement on at least one side of
the body, with either impaired
consciousness, global aphasia,
or lack of response indicating
cognition (Glasgow Coma Scale
score of less than 9, Canadian
Neurological Scale score of less
than 5.0).
2.
Life-Threatening Brain Damage
Life-threatening brain damage is
associated with brain stem
compression caused by large
intracerebral hemorrhage (ICH),
usually with intraventricular
extension; large hemispheric
infarction with midline shift;
infratentorial strokes involving
multiple levels in the brain
stem; or cerebellar lesions.*
3.
Significant Comorbidities
The
following nonneurological
conditions are important risk
factors for death within the
first month after stroke:
pneumonia, pulmonary embolism,
sepsis, recent myocardial
infarction, cardiomyopathy, and
life-threatening arrhythmias.
These comorbid factors should be
considered part of expected
consequences of severe stroke
pointing to an increased
likelihood of death in the
subacute phase of stroke.
*Fatal
outcome of ICH is associated
with a volume of > 60 mL on CT
scans. Currently available data
lack precision in quantifying
imaging criteria and size of
life-threatening hemispheric
infarctions and infratentorial
lesions.
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