The medication, tissue plasminogen activator, or tPA,
typically does not save a patient's life following a stroke. But
people who receive tPA or similar drugs tend to have better mental
functioning after a stroke and are more likely to be able to live
independently, according to Dr. Winston Chiong.
Chiong led the new study at the University of California, San
"There's been a controversy within not just neurology but a number
of the disciplines about how to manage this really difficult ethical
situation . . . when patients are unable to speak for themselves,"
he told Reuters Health.
"They might be unable to speak because of a stroke, or be unable to
communicate, or in some cases they might not be aware of the fact
that they've been debilitated by the stroke."
In recent years, both the American Academy of Neurology and the
American Heart Association/American Stroke Association have released
statements supporting the use of tPA for stroke patients who are
unable to consent, and when a family member is not present.
The treatment remains underutilized, Chiong said, with less than 5
percent of stroke patients receiving clot-busting medication.
One reason is that tPA is time-sensitive and guidelines say it
should only be given to patients who have had a stroke within the
past few hours. The medication comes with a risk of bleeding,
including bleeding in the brain, so after too long a delay the
potential benefits may no longer outweigh the risks.
"If the medication is given early, say within the first three or
four and a half hours, it doesn't increase the risk of death. But
there may be some patients who are harmed by the medication," Chiong
"That's been the main cause for reluctance on the part of many
physicians to use this medicine, particularly when the patient can't
engage in a conversation about the risks and benefits."
To see how older adults feel about potentially receiving tPA after a
stroke, he and his colleagues analyzed data from a
nationally-representative online survey of 1,100 people ages 50 and
older. Half of participants where asked about their wishes in a
hypothetical case of cardiac arrest and the other half in a case of
Twenty-four percent of participants asked about stroke said they
would not want to receive tPA or similar medications if they arrived
at the hospital after having a stroke, according to the findings
published Tuesday in the Journal of the American Medical
The other participants were asked if
they would want to be given CPR after a sudden cardiac arrest. A
similar proportion said they would not want treatment.
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It's generally accepted that doctors and paramedics can ethically
give CPR to a person whose heart has stopped and who cannot consent.
So the researchers wanted to compare how potential patients saw both
"For us, this highlights the fact that these situations ... are
really difficult," Chiong said. "It's really about this dilemma that
many physicians find themselves in of treating patients when we
don't know what their preferences are."
That might mean treating a patient with a severe stroke with tPA
even when it seems risky to do so.
The survey results show that doctors can provide care that is
consistent with most people's wishes by giving tPA and related
medications to eligible stroke patients, Chiong said. But it's still
better to know what the individual patient would have wanted.
Because of that, he said the study emphasizes the importance of
speaking with family, friends and doctors about treatment wishes
before anything goes wrong, and writing those wishes down in advance
directives. It's also an opportunity to reinforce the importance of
getting patients to a hospital in time for medications like tPA to
"It's most important that people are aware that treatments exist and
that if somebody experiences or witnesses a suspected stroke, they
should call 911 and that patient should be taken to the hospital by
ambulance," he said.
Journal of the American Medical Association, online April 22, 2014.
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