Patient preferences not often asked after stroke hospitalization

Daughter holding her mother hand, that injected with IV in hospital (©Rudyanto Wijaya)

Less than half of stroke patients who were hospitalized and died within 30 days had their preferences for lifesaving measures recorded in a recent study of California hospitals.

"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," Robinson said.

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 study.

"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.