Most patients who die of ICH do so during the initial acute hospitalization, and these deaths usually occur in the setting of withdrawal of support because of presumed poor Palliative care is an important aspect of care for patients with severe ICH and their families whether or not withdrawal of support is being pursued, and this is discussed in substantially more detail in the recently released American Heart Association scientific statement on Palliative and End- of-Life Care in Stroke. 259 Several studies, however, have identified withdrawal of medical support and other early care limitations, such as DNAR orders within the first day of hospi- talization, as independent predictors of outcome.260 262 By defi- nition, a DNAR order means that there should be no attempt at resuscitation should a cardiopulmonary arrest occur. In practi- cal use, however, DNAR orders are a proxy for overall lack of aggressive care when administered early after ICH, and the overall aggressiveness of ICH care at a hospital is associated with patient outcomes, even after controlling for specific indi- The decision to limit care early after ICH may therefore result in self-fulfilling prophecies of poor outcome, and studies show that current outcome predic- tion models are overly pessimistic because of the failure to account for these care limitations.264,265 Prognostication early after ICH is often desired by physicians, patients, and families, but existing prognostic models are biased by limitation-of-care decisions. Providers should therefore be cautious about offering precise prog- noses early after ICH, especially if the purpose of prog- nostication is to consider withdrawal of support or DNAR Aggressive, guideline-concordant therapy is thus recommended for patients with ICH who do not have advanced directives specifying that such care should not be undertaken. 