Abstract
Stroke is one of the leading causes of death and long-term disability in the United States. Though advances in interventions have improved patient survival after stroke, prognostication of long-term functional outcomes remains challenging, thereby complicating discussions of treatment goals. Stroke patients who require intensive care unit care often do not have the capacity themselves to participate in decision making processes, a fact that further complicates potential end-of-life care discussions after the immediate post-stroke period. Establishing clear, consistent communication with surrogates through shared decision-making represents best practice, as these surrogates face decisions regarding artificial nutrition, tracheostomy, code status changes, and withdrawal or withholding of life-sustaining therapies. Throughout decision-making, clinicians must be aware of a myriad of factors affecting both provider recommendations and surrogate concerns, such as cognitive biases. While decision aids have the potential to better frame these conversations within intensive care units, aids specific to goals-of-care decisions for stroke patients are currently lacking. This mini review highlights the difficulties in decision-making for critically ill ischemic stroke and intracerebral hemorrhage patients, beginning with limitations in current validated clinical scales and clinician subjectivity in prognostication. We outline processes for identifying patient preferences when possible and make recommendations for collaborating closely with surrogate decision-makers on end-of-life care decisions.
Highlights
INTRODUCTIONStroke is a leading cause of death and long-term disability in the United States (US) [1, 2]
EPIDEMIOLOGY OF LIFE-SUSTAINING THERAPY FOR SEVERE STROKE PATIENTSStroke is a leading cause of death and long-term disability in the United States (US) [1, 2]
The term “stroke” for this review focuses on two subtypes: acute ischemic stroke (AIS) and intracerebral hemorrhage (ICH)
Summary
Stroke is a leading cause of death and long-term disability in the United States (US) [1, 2]. Some published data suggest that scales largely outperform the “subjective” opinion of clinicians at predicting mortality and functional disability [41,42,43] These studies generally involved asking clinicians to prognosticate expected outcomes from hypothetical patient vignettes, which simplify and distill information that would otherwise be available in real-world clinical practice. Clinicians have been shown to be poor at predicting a patient’s future QoL, an inherently subjective quality, after stroke [47,48,49] Despite these limitations, disclosing the results of a prognostication scale for a patient to a clinician impacts that clinician’s clinical impression [50]. As a means to this end, ACPs and surrogate decision-makers represent two sources of information for clinicians
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