Unifying Concepts

Clinical Criteria for Do-Not-Resuscitate (DNR) Orders in Acute Stroke

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.



  1. Alexandrov AV, Pullicino PM, Meslin EM, Norris JW. Agreement on disease-specific criteria for do-not-resuscitate orders in acute stroke. Members of the Canadian and Western New York Stroke Consortiums. Stroke. 1996 Feb;27(2):232-7. [Medline]


Created: Jun 17, 2007

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