Physicians failing to talk to stroke patients about end-of-life treatment preferences

By Lucy Piper

US research suggests that physician-patient discussion about limitations on life-sustaining interventions following ischaemic stroke is low, poorly documented and often left too late.

Among 198 patients, aged 80 years on average, who died within 30 days of admission to hospital due to stroke, less than 40% had discussions with their physicians about limitations on life-sustaining interventions documented during the index hospitalisation.

Even among patients who died while in hospital or were discharged to hospice, only 50% had documented discussions about end-of-life treatment.

This was despite 47% of patients documenting at or within 48 hours of admission their desire to forgo at least one life-sustaining intervention.

"This suggests that there is an opportunity to improve patient-physician communication, and thus the quality of palliative care in stroke, in the early poststroke period", say lead researcher Maisha Robinson (Mayo Clinic, Jacksonville, Florida, USA) and colleagues.

Indeed, their findings showed that for most patients discussions occurred just 5 days before death and although unable to discern the reasons for this lateness, the researchers propose it could be due to worsening or lack of improvement of the patient's clinical condition or due to episodes of poor quality of care leading to clinical deterioration.

Physician communication was a significant 56% less likely to be documented for patients with mild to severe stokes than for those with very severe strokes, particularly regarding preferences for cardiopulmonary resuscitation.

"It is plausible that physicians are more comfortable initiating discussions about end-of-life care decisions in catastrophic situations or that these discussions more often lead to documented decisions to withhold life-sustaining interventions with severe strokes relative to milder ones, or both", suggests the team in Neurology.

Ying Xian (Duke University Medical Center, Durham, North Carolina, USA) and Winston Chiong (University of California, San Francisco, USA) stress in a related editorial that the highly preference-sensitive nature of decisions on life-sustaining therapy after acute ischaemic stroke and their ability to "profoundly influence consequent mortality" make them "essential" to ensure high-quality care.

They conclude: "As has been noted elsewhere, such failures to incorporate patient preferences are themselves preventable medical errors, and these errors are particularly consequential in the setting of ischemic stroke."

"Future initiatives to improve safety and reduce preventable errors in stroke care should include efforts to identify contributing factors associated with the lack of communication, develop interventions to promote healthy dialog among patients, their families, and the health care team, and ultimately improve patient-centered care at the end of life for stroke patients."

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