Ethical approach to surrogate consent for hemicraniectomy in older patients with extensive middle cerebral artery stroke.

Abstract

See related article, p 2830. The recently published Decompressive Surgery for the Treatment of Malignant Infarction of the Middle Cerebral Artery (DESTINY) II trial1 has reignited the controversy over performing hemicraniectomy in the elderly population, highlighting the question of how preference-based medicine2 should be applied to patients with severe stroke. The trial concluded that hemicraniectomy increased survival without severe disability.1 The surgically treated group had better scores across multiple outcome measures including the percentage with no to moderately severe disability (score of 0–4 on the modified Rankin scale) and mean scores on scales assessing stroke severity (the National Institutes of Health Stroke Scale [NIHSS]), activities of daily living (Barthel Index), quality of life (the Short Form-36 Health Survey scales), depression (Hamilton Depression Rating Scale), and self-assessment of overall health (EuroQOL scales).3 However, the majority of survivors required assistance with most bodily needs.1 No patients in the surgical group had zero or slight disability, one third were dead at 6 months, and nearly one third were bedridden, incontinent, and requiring constant nursing care and attention. The high degree of outcome disability after hemicraniectomy in older patients raises vexing ethical issues of communication with and consent by surrogate family members. Before this study, one third of hemicraniectomy procedures performed for ischemic stroke were done in patients >65 years of age, and the overall rate has increased over the past decade.4,5 As the population ages and stroke care becomes more aggressive and better organized regionally, the number of eligible patients will likely continue to rise.4 Here, we offer an ethical framework for consent for hemicraniectomy that integrates outcome data with patients’ values and preferences. The ethical foundation of medical decision making is informed consent. Clinicians require the informed consent of capacitated patients or …