EVD Placement in a DNR Patient with Midbrain Hemorrhage and Hydrocephalus (GCS 5)
A DNR order does not automatically preclude EVD placement, but in this specific clinical scenario—a patient with metastatic cancer, GCS 5, and midbrain hemorrhage with hydrocephalus—EVD placement is not indicated and should not be performed. 1
Why EVD Should Not Be Placed in This Case
GCS 5 is Below the Evidence-Based Threshold
EVD is contraindicated in patients with GCS ≤3 and has extremely limited benefit in GCS 4-5. 1 The evidence supporting EVD placement specifically excludes patients with GCS ≤3 due to universally poor prognosis regardless of intervention. 1
In research examining EVD outcomes, 33 of 39 patients (85%) with GCS 3-5 at the time of EVD insertion died, compared to 20 of 51 patients (39%) with GCS 6-8. 2 This demonstrates that EVD provides minimal mortality benefit at GCS 5.
The American Heart Association guidelines recommend EVD for patients with GCS >3 and hydrocephalus causing decreased consciousness. 1 At GCS 5, the patient falls into a gray zone where survival is possible but functional recovery is highly unlikely.
EVD Reduces Mortality But Not Functional Outcomes
While EVD placement reduces mortality in ICH/IVH with hydrocephalus, the benefit for improving functional outcomes is not well established. 3, 1 This is a critical distinction when considering goals of care in a DNR patient.
In patients with moderate to severe ICH/IVH and reduced consciousness (GCS <13), EVD improves survival but does not clearly improve neurologic outcomes. 3, 4
88% of survivors after EVD placement for severe ICH had poor functional outcomes (mRS 3-5), with many left moderately to severely disabled or in vegetative states. 2
Metastatic Cancer Context Changes the Risk-Benefit Calculus
The presence of metastatic cancer fundamentally alters the treatment goals. 1 A DNR order typically reflects discussions about limiting aggressive interventions that prolong dying rather than restore meaningful function.
EVD is an invasive procedure with significant complications: infection rates of 27.6%, 2 hemorrhagic complications, and the need for ICU-level care with potential progression to permanent shunt dependency in 8.9-48% of survivors. 5
When EVD Would Be Appropriate (For Contrast)
EVD placement is strongly indicated in different clinical scenarios:
Patients with GCS 9-12 and hydrocephalus have significantly better outcomes, with only 8 of 35 patients (23%) dying in this group. 2
Patients with GCS 6-8 represent a middle ground where EVD can be considered if goals of care support aggressive intervention. 2
For aneurysmal SAH with hydrocephalus (not metastatic hemorrhage), EVD is Class 1 indication when it causes decreased consciousness, as it reduces mortality. 3, 5, 1
DNR Does Not Equal "Do Not Treat"—But Context Matters
A DNR order addresses resuscitation in the event of cardiopulmonary arrest, not all medical interventions. 5 However, it often signals broader goals-of-care discussions about the intensity of interventions.
The key question is whether EVD aligns with the patient's goals: If the goal is comfort-focused care, EVD placement—which requires ICU monitoring, repeated procedures, and carries infection risk—is inconsistent with that goal. 5, 1
If the DNR reflects only a desire to avoid chest compressions but otherwise pursue aggressive care, then EVD could theoretically be considered—but the GCS 5 and metastatic cancer make meaningful recovery extremely unlikely. 1, 2
Common Pitfalls to Avoid
Do not equate "EVD reduces mortality" with "EVD should be placed." 3 Mortality reduction without functional benefit may not align with patient values, especially in metastatic cancer with DNR status.
Do not delay goals-of-care discussions. 5 This clinical scenario demands urgent clarification of whether the patient would want to survive with severe disability or vegetative state.
Do not place EVD reflexively based on imaging alone. 1 The combination of GCS 5, midbrain location (poor prognosis), metastatic cancer, and DNR status makes this a case where comfort measures are more appropriate than invasive neurosurgical intervention.