“All patients admitted to the hospital for a stroke should have a
conversation with the clinical team about their goals of care, which
should include a discussion about life-sustaining interventions,”
said lead author Dr. Maisha T. Robinson of the neurology department
at the Mayo Clinic in Jacksonville, Florida. “Ideally, conversations
about advance care planning should occur well in advance of
hospitalizations for serious illnesses.”
Clinicians, patients or family members may be hesitant to address
end-of-life issues because it is difficult or uncomfortable, she
told Reuters Health by email.
“Patients who have not documented their preferences for
life-sustaining treatments and who are unable to engage in the
conversations during the hospitalization due to cognitive or
functional impairment must rely on their designated health care
surrogates or their proxies to make decisions on their behalf,”
The researchers used a California patient discharge database to
identify a group of adults hospitalized for stroke at acute care
hospitals in 2007. They selected 39 hospitals and 981 stroke
admissions, limiting their analysis to the 198 patients who died
within 30 days of admission.
On average, patients were 80 years old, most were admitted from home
and 42 percent died during their initial hospitalization.
Only 39 percent of patients had their preferences for at least one
lifesaving intervention recorded, most often it was their desire for
cardiopulmonary resuscitation (CPR), followed by their preferences
regarding mechanical ventilation, nasal tube feeding and feeding
through a tube in the abdominal wall.
Almost 44 percent of patients indicated that they did not want CPR,
20 percent did not want mechanical ventilation and 6 percent did not
want nasal or gastric tube feeding.
People with more severe strokes were more likely to have preference
documentation than those with milder strokes, as reported in
Neurology. Most discussions about preferences took place within five
days of death.
“Decisions regarding extending or limiting life-sustaining therapy
after acute ischemic stroke are very dependent on patient and family
preference, stroke severity, prognosis, and whether protocols are in
place to prompt discussion,” said Dr. Gregg C. Fonarow of the David
Geffen School of Medicine at UCLA, who was not part of the new
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“Discussion and clear documentation of patient preferences for
resuscitation and other life-sustaining interventions in the medical
record is vital to ensure that patients do not receive care that is
not appropriate given their preference.”
These discussions include the physician, patient and family or
designated healthcare proxy and usually take place during the
initial evaluation or early in the hospitalization, Fonarow told
Reuters Health by email.
“There are a multitude of vital aspects of stroke care that should
be taking place during hospitalization, and often some get
overlooked, unless highly reliable systems are in place at each and
every hospital,” he said.
“I’m not sure that it needs to happen in all stroke patients in my
opinion,” said Dr. Adam G. Kelly of the University of Rochester
Medical Center in New York, who was also not part of the study. “But
there are certain populations (older adults, patients with severe
strokes, patients with multiple other chronic medical conditions)
where the likelihood of death or needing a high intensity
intervention (such as a feeding tube) are much higher,” he said.
“In these groups, these discussions need to happen and the content
of these discussions should absolutely be recorded,” Kelly said.
SOURCE: http://bit.ly/1TlxXGn Neurology, online April 8, 2016.
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