Treatment Decisions After Severe Stroke

Abstract

Stroke demands our attention because it is common, disabling, and deadly. One in 15 patients requires mechanical ventilation on admission, 1 in 20 patients is discharged from the acute care hospital with a feeding tube, and 1 in 5 patients requires institutional care at 3 months after stroke.1 Most patients with severe stroke who die, do so in the setting of withdrawal of life-sustaining treatment (LST),2 and this decision is typically made by physicians who predict a poor outcome and surrogates who are asked to articulate the patient’s preferences3: "she would not want to live like that." When prognosis is certain and the outcome unacceptable, the decision to withdraw or withhold LST may be relatively straightforward, although emotionally challenging. In most severe strokes, however, decisions are made when prognosis is uncertain and when what constitutes an acceptable outcome is unknown. In this article, we explore the uncertainties and biases that influence these life-and-death decisions. Such biases can lead to errors in decision making and ultimately the overuse or underuse of LST. Hence, the need is urgent to understand better the factors that contribute to optimal -decision making.4 Surviving a severe stroke means living with disability. Treatment decisions, thus, frequently involve trade-offs.5 Three typical preference-sensitive decisions after severe stroke are mechanical ventilation, artificial nutrition, and surgical decompression for hemorrhagic or ischemic strokes with life-threatening mass effect. All of these LSTs reduce the risk of death but increase the chance of survival.6–8 Although one individual may choose life at all costs, even when evidence predicts severe disability, another may refuse LSTs despite a prospect of surviving with a modest deficit, trading off the possibility of survival in an undesirable health state for the more desirable outcome of death. In the acute setting, withdrawal …