Saturday, May 27, 2017

End-of-Life Care After Stroke Varies Widely

Likely because they have not done any objective 3d scans of the dead and dying areas to know how bad the stroke was.  

End-of-Life Care After Stroke Varies Widely


Transition to palliative care varies by patient and hospital factors

  • by
    Contributing Writer, MedPage Today

Action Points

  • Note that this observational study found that the use of "comfort measures only" for stroke patients varies significantly from hospital to hospital.
  • This variation is not solely due to hospital acuity levels, suggesting that approach to these patients might benefit from more standardization.
Early use of comfort measures only following admission for acute stroke varies widely between hospitals, as influenced by hospital and patient characteristics, researchers reported.
Overall, about one in 20 people (5.6%) were transitioned from traditional or aggressive acute treatment to comfort measures only (CMO) within 48 hours of admission for acute hemorrhagic or ischemic stroke, Shyam Prabhakaran, MD, of Northwestern University in Chicago, and colleagues reported online in Neurology: Clinical Practice.
However, early use of a palliative approach by individual hospitals ranged widely, from less than 1% of people with stroke to 38%, and rates among those with intracerebral hemorrhage reached 76% at some hospitals.
Early palliative care was more likely to be initiated in rural than in urban hospitals, in hospitals in the Midwest, South, and West regions versus those in the Northeast, and in smaller hospitals.
Palliative care was more commonly ordered early for those with an intracerebral hemorrhage (19.4%) or subarachnoid hemorrhage (13.1%) – which are associated with higher mortality – and less likely for those with ischemic stroke (3.0%).
Overall, use of comfort-only measures declined during the study period from 6.1% in 2009 to 5.4% in 2013 (P<0.001) in the analysis of 4 years of data from 963,525 patients attending 1,675 hospitals included in the Get With The Guidelines–Stroke registry.
"End-of-life and palliative care plays an important role with stroke, since the death rate is high yet there has been limited data on the transition from treatment to comfort care," Prabhakaran said in a statement.
Approximately 10% of ischemic stroke patients and up to 30% of hemorrhagic stroke patients die within 30 days following stroke, a reality reflected in the American Heart Association/American Stroke Association's 2014 scientific statement concerning core concepts, skills, and expectations surrounding end-of-life care services for stroke patients, the researchers noted.
(this could be reduced substantially if the neuronal cascade of death was stopped)
Prabhakaran's group distinguished between comfort-only measures and do-not-resuscitate orders, which do not limit intensive acute stroke treatments, noting that use of CMO before a clear prognosis has been made may be detrimental.
The correlation between hospital-level risk-adjusted mortality and the use of early comfort measures only was stronger for subarachnoid hemorrhage (r=0.52) and intracerebral hemorrhage (r=0.50) than for acute ischemic stroke (r=0.15) patients.
Multivariable analysis for all strokes found the following factors significantly and independently associated with early versus no comfort-only measures:
  • Intracerebral or subarachnoid hemorrhage (OR 6.79 and 6.94, respectively)
  • Older age (OR 1.85 per 10 years beyond age 65)
  • Female sex (OR 1.26)
  • White race (OR 0.64 for non-Hispanic black and 0.78 for Hispanic)
  • Medicaid and self-pay/no insurance (OR 1.08 and 1.21, respectively)
  • Arrival by ambulance or off-hours (OR 3.96 and 1.10, respectively)
  • Non-ambulatory status pre-stroke (OR 2.36)
Among medical risk factors, atrial fibrillation and coronary artery disease were associated with increased odds of early CMO use, while hypertension, diabetes, dyslipidemia, prior stroke or transient ischemic attack, carotid stenosis, and smoking history were associated with lower odds of early CMO use.
"Severe stroke is a common event often close to one's death that unleashes a series of intense conversations among doctors, patients and families about what health states are acceptable or unacceptable and what makes life worth living," Robert Holloway, MD, MPH, of New York's University of Rochester Medical Center, and James L. Bernat, MD, of Dartmouth in Hanover, N.H., wrote in an accompanying editorial.
Given that discussions about preferences for life-limiting therapies were documented in fewer than 40% of dying stroke patients (based on a study of 2006-2007 data), considerable quality improvement opportunities remain, Holloway noted. "This study gives us insights into how these transitions are happening and will stimulate discussion about how we can improve this process to help ensure that care is high quality and consistent with the patient's goals."
Limitations noted by researchers include the lack of evaluation of specific clinical and radiographic factors (including level of consciousness and brainstem function) that affect prognosis after stroke, the absence of do-no-resuscitate order data in the GWTG-Stroke registry, and the inclusion of early but not late CMO data that likely resulted in underestimation of the effect of comfort measures only on in-hospital mortality at the hospital level.
No targeted study funding was reported.
Prabhakaran served as a section editor for Current Atherosclerosis Reports, receives publishing royalties from UpToDate, and receives research support from NIH/National Institute of Neurological Disorders and Stroke and PCORI.
The editorialists disclosed no relevant relationships with industry.
  • Reviewed by F. Perry Wilson, MD, MSCE Assistant Professor, Section of Nephrology, Yale School of Medicine and Dorothy Caputo, MA, BSN, RN, Nurse Planner
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