Abstract
Stroke is a leading cause of disability and mortality worldwide. Recent advances in stroke care now enable patients with severe ischemic stroke owing to large vessel occlusion to safely undergo endovascular thrombectomy (EVT) up to 24 hours since their time of last known well, with the goal of improving functional outcomes by recanalization of the occluded vessel and reperfusion of downstream ischemic brain tissue. The objective of this analysis is to highlight clinical and ethical challenges related to ensuring goal-concordant care in this era of unprecedented advances in acute stroke care. Specifically, there is a salient challenge of whether advanced therapies such as EVT may be justifiably considered comfort focused, given their potential to preempt accumulated neurologic disability and suffering at the end of life. Through the lens of a patient case, we discuss key challenges, lessons learned, and suggestions for future care and research endeavors at the intersection of acute stroke care and palliative care principles. Although therapies such as thrombolysis and EVT may be considered aggressive prima facie, their potential to ameliorate additional disability and potential suffering at the end of life prompt close consideration of the proper role of these therapies on a case-by-case basis in the context of comfort-focused care. Modification to the workflow for EVT evaluations may facilitate goal-concordant care and timely resource allocation, especially for cases that involve hospital-to-hospital transfers for advanced stroke care.
Highlights
Stroke is a leading source of disability and mortality in the world, second only to heart disease.[1]
Recent advances in stroke care enable patients with severe ischemic stroke owing to large vessel occlusion to safely undergo endovascular thrombectomy (EVT) up to 24 hours since their time of last known well, with the goal of improving functional outcomes by recanalization of the occluded vessel and reperfusion of downstream ischemic brain tissue
Intravenous thrombolysis with tissue plasminogen activator is the mainstay of acute ischemic stroke therapy, only approximately 5% of patients are eligible for such treatment.[1]
Summary
Stroke is a leading source of disability and mortality in the world, second only to heart disease.[1]. The medical team underscored that, tPA was one type of acute stroke therapy, EVT could potentially remove the clot, possibly decreasing his neurologic deficits and preventing further disability His daughter highlighted that several months before his admission he had expressed a preference for a do-notresuscitate (DNR) order when admitted to the hospital for viral gastroenteritis. His daughter unequivocally indicated that her father should not receive any medical interventions aimed at prolonging life, in line with her understanding of his prior wishes She predicated this on his recent behaviors and conversations, including his refusal to take anticoagulation despite a cardiologist’s recommendations, declining a pacemaker a year before his stroke, and consistent opposition to medical procedures. The palliative medicine service was consulted, and ensured that the surrogate participated in informed shared decision making with proper understanding, appreciation, and communication around the reasoning for forgoing life-sustaining treatments.[8]
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