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Shlobin NA, Regenhardt RW, Young MJ. Ethical Considerations in Endovascular Thrombectomy for Stroke. World Neurosurg 2024; 185:126-134. [PMID: 38364896 DOI: 10.1016/j.wneu.2024.02.047] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2024] [Revised: 02/07/2024] [Accepted: 02/08/2024] [Indexed: 02/18/2024]
Abstract
INTRODUCTION Stroke is a leading cause of morbidity and mortality globally. Endovascular mechanical thrombectomy is considered for patients with large vessel occlusion stroke presenting up to 24 hours from onset and is being increasingly utilized across diverse clinical contexts. Proactive consideration of distinctive ethical dimensions of endovascular thrombectomy (EVT) can enable stroke care teams to deliver goal-concordant care to appropriately selected patients with stroke but have been underexplored. METHODS A narrative review with case examples was conducted. RESULTS We explain and critically evaluate the application of foundational bioethical principles and narrative ethics to the practice of EVT, highlight key ethical issues that may emerge in neuroendovascular practice and develop an ethical framework to aid in the responsible use of EVT for people with large-vessel occlusive ischemic stroke. CONCLUSIONS EVT for stroke introduces important ethical considerations. Salient challenges include decision-making capacity and informed consent, the telos of EVT, uncertainty, access to care, and resource allocation. An ethical framework focusing on combining patient values and preferences with the best available evidence in the context of a multidisciplinary care team is essential to ensure that the benefits of EVT are responsibly achieved and sustained.
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Affiliation(s)
- Nathan A Shlobin
- Department of Neurological Surgery, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA.
| | - Robert W Regenhardt
- Departments of Neurosurgery and Neurology, Neuroendovascular Service, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Michael J Young
- Department of Neurology, Center for Neurotechnology and Neurorecovery, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
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Mbonde A, Young MJ, Dmytriw AA, Moyer QJ, Hirsch JA, Leslie-Mazwi TM, Rost NS, Patel AB, Regenhardt RW. Informed consent practices for acute stroke therapy: principles, challenges and emerging opportunities. J Neurol 2024; 271:188-197. [PMID: 37815578 DOI: 10.1007/s00415-023-12028-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2023] [Revised: 09/24/2023] [Accepted: 09/25/2023] [Indexed: 10/11/2023]
Abstract
IMPORTANCE Informed consent (IC) plays a crucial yet underexplored role in acute stroke treatment, particularly in the context of intravenous thrombolysis (IVT) and endovascular thrombectomy (EVT). This narrative review examines data on current IC practices in acute ischemic stroke management, specifically for patients treated with IVT or EVT, with the aim of identifying areas for improvement and strategies to enhance the IC process. OBSERVATIONS IC practices for IVT vary significantly among hospitals and physicians with the frequency of always requiring consent ranging from 21 to 37%. Factors influencing IC for IVT include patient decision-making capacity, standard of care, time sensitive nature of treatments, legal and moral obligations, risk of complications, physician age and speciality, treatment delays, and hospital size. Consent requirements tend to be stricter for patients presenting within the 3-4.5-h window. The content and style of information shared as part of the IC process revealed discrepancies in the disclosure of stroke diagnosis, IVT mechanism, benefits, and risks. Research on IC practices for EVT is scarce, highlighting a concerning gap in the available evidence base. CONCLUSIONS AND RELEVANCE This review underscores the significant variability and knowledge gaps in IC for EVT and IVT. Challenges related to decision-making capacity assessment and the absence of standardised guidance substantially contributes to these gaps. Future initiatives should focus on simplifying information delivery to patients, developing formal tools for assessing capacity, standardising ethical frameworks to guide physicians when patients lack capacity and harmonizing IC standards across sites. The ultimate goal is to enhance IC practices and uphold patient autonomy, while ensuring timely treatment initiation.
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Affiliation(s)
- Amir Mbonde
- Harvard Medical School, Boston, MA, USA.
- Mayo Clinic Arizona, 13400 E Shea Blvd, Scottsdale, AZ, 85259, USA.
| | | | - Adam A Dmytriw
- Harvard Medical School, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
| | - Quentin J Moyer
- Harvard Medical School, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
| | | | | | | | | | - Robert W Regenhardt
- Harvard Medical School, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
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Zonjee VJ, Slenders JPL, de Beer F, Visser MC, Ter Meulen BC, Van den Berg-Vos RM, van Schaik SM. Practice variation in the informed consent procedure for thrombolysis in acute ischemic stroke: a survey among neurologists and neurology residents. BMC Med Ethics 2021; 22:114. [PMID: 34433444 PMCID: PMC8390276 DOI: 10.1186/s12910-021-00684-6] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2021] [Accepted: 08/18/2021] [Indexed: 11/17/2022] Open
Abstract
Background Obtaining informed consent for intravenous thrombolysis in acute ischemic stroke can be challenging, and little is known about if and how the informed consent procedure is performed by neurologists in clinical practice. This study examines the procedure of informed consent for intravenous thrombolysis in acute ischemic stroke in high-volume stroke centers in the Netherlands. Methods In four high volume stroke centers, neurology residents and attending neurologists received an online questionnaire concerning informed consent for thrombolysis with tissue-type plasminogen activator (tPA). The respondents were asked to report their usual informed consent practice for tPA treatment and their considerations on whether informed consent should be obtained. Results From the 203 invited clinicians, 50% (n = 101) completed the questionnaire. One-third of the neurology residents (n = 21) and 21% of the neurologists (n = 8) reported that they always obtain informed consent for tPA treatment. If a patient is not capable of providing informed consent, 30% of the residents (n = 19) reported that they start tPA treatment without informed consent. In these circumstances, 53% of the neurologists (n = 20) reported that the resident under their supervision would start tPA treatment without informed consent. Most neurologists (n = 21; 55%) and neurology residents (n = 45; 72%) obtained informed consent within one minute. None of the respondents used more than five minutes for informed consent. Important themes regarding obtaining informed consent for treatment were patients’ capacity, and medical, ethical and legal considerations. Conclusion The current practice of informed consent for thrombolysis in acute ischemic stroke varies among neurologists and neurology residents. If informed consent is obtained, most clinicians stated to obtain informed consent within one minute. In the future, a shortened information provision process may be applied, making a shift from informed consent to informed refusal, while still considering the patient’s capacity, stroke severity, and possible treatment delays. Supplementary Information The online version contains supplementary material available at 10.1186/s12910-021-00684-6.
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Affiliation(s)
- Valentijn J Zonjee
- Department of Neurology, OLVG, Jan Tooropstraat 164, 1061 AE, Amsterdam, The Netherlands.
| | - Jos P L Slenders
- Department of Neurology, OLVG, Jan Tooropstraat 164, 1061 AE, Amsterdam, The Netherlands
| | - Frank de Beer
- Department of Neurology, Spaarne Gasthuis, Haarlem, The Netherlands
| | - Marieke C Visser
- Department of Neurology, Amsterdam UMC, Location VUmc, Amsterdam, The Netherlands
| | - Bastiaan C Ter Meulen
- Department of Neurology, OLVG, Jan Tooropstraat 164, 1061 AE, Amsterdam, The Netherlands
| | - Renske M Van den Berg-Vos
- Department of Neurology, OLVG, Jan Tooropstraat 164, 1061 AE, Amsterdam, The Netherlands.,Department of Neurology, Amsterdam UMC, Location AMC, Amsterdam, The Netherlands
| | - Sander M van Schaik
- Department of Neurology, OLVG, Jan Tooropstraat 164, 1061 AE, Amsterdam, The Netherlands
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Skolarus LE, Neshewat GM, Evans L, Green M, Rehman N, Landis-Lewis Z, Schrader JW, Sales AE. Understanding determinants of acute stroke thrombolysis using the tailored implementation for chronic diseases framework: a qualitative study. BMC Health Serv Res 2019; 19:182. [PMID: 30894152 PMCID: PMC6425596 DOI: 10.1186/s12913-019-4012-6] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2018] [Accepted: 03/14/2019] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND The Tailored Implementation in Chronic Disease (TICD) framework is a comprehensive framework describing the determinants of implementation success that has been used extensively in primary care settings. We explored the utility of the TICD to identify determinants of practice in an acute setting, namely guideline concordant acute stroke thrombolysis in a low-resourced, predominately minority serving, large, Emergency Department (ED). METHODS Through workshops and expert review, we developed an interview guide informed by the TICD framework. We then conducted semi-structured interviews with data collected through written transcripts, audio transcripts or interviewer notes based on participant availability. Three independent coders then performed a content analysis using template analysis, but open to new determinants that arose from the data, into the TICD framework. RESULTS We performed a total of 15 semi-structured interviews with ED acute stroke providers including medical technicians, nurses, and physicians. We found that guideline factors, individual health professional factors, and patient factors domains were barriers to guideline concordant acute stroke thrombolysis. The domain professional interactions was a facilitator to treatment. We identified three determinants, healthcare professional burnout, health care professional turnover and surrogate decision making, that are not part of the TICD framework. CONCLUSIONS Most determinants of acute stroke thrombolysis are included within the TICD framework. Inclusion of healthcare professional burnout, healthcare professional turnover and surrogate decision making may assist in expanding the TICD to time-sensitive ED conditions. Further work is needed to confirm this finding and to establish whether the TICD is applicable for use in non-time sensitive ED conditions. Interventions that address guideline, individual health professional and patient factors may improve guideline concordant acute stroke thrombolysis.
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Affiliation(s)
- Lesli E. Skolarus
- Stroke Program, Department of Neurology, University of Michigan, 1500 E Medical Center Dr, SPC 5856, Ann Arbor, MI 48109-5856 USA
- School of Public Health, University of Michigan, Ann Arbor, MI USA
| | - Gina M. Neshewat
- Stroke Program, Department of Neurology, University of Michigan, 1500 E Medical Center Dr, SPC 5856, Ann Arbor, MI 48109-5856 USA
| | - Lacey Evans
- Stroke Program, Department of Neurology, University of Michigan, 1500 E Medical Center Dr, SPC 5856, Ann Arbor, MI 48109-5856 USA
| | - Molly Green
- Stroke Program, Department of Neurology, University of Michigan, 1500 E Medical Center Dr, SPC 5856, Ann Arbor, MI 48109-5856 USA
- School of Public Health, University of Michigan, Ann Arbor, MI USA
| | - Narmeen Rehman
- Stroke Program, Department of Neurology, University of Michigan, 1500 E Medical Center Dr, SPC 5856, Ann Arbor, MI 48109-5856 USA
| | - Zach Landis-Lewis
- Department of Learning Health Science, University of Michigan, Ann Arbor, USA
| | | | - Anne E. Sales
- Department of Learning Health Science, University of Michigan, Ann Arbor, USA
- Center for Clinical Management Research, Veterans Affairs Ann Arbor Healthcare System, Ann Arbor, MI USA
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Majersik JJ, Morgenstern LB. Informed consent in acute ischemic stroke: It's on us. Neurology 2018; 90:203-204. [PMID: 29298850 DOI: 10.1212/wnl.0000000000004903] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Affiliation(s)
- Jennifer J Majersik
- From Neurology (J.J.M.), University of Utah, Salt Lake City; and Neurology (L.B.M.), University of Michigan, Ann Arbor.
| | - Lewis B Morgenstern
- From Neurology (J.J.M.), University of Utah, Salt Lake City; and Neurology (L.B.M.), University of Michigan, Ann Arbor
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Mendelson SJ, Aggarwal NT, Richards C, O'Neill K, Holl JL, Prabhakaran S. Racial disparities in refusal of stroke thrombolysis in Chicago. Neurology 2018; 90:e359-e364. [PMID: 29298854 PMCID: PMC10681073 DOI: 10.1212/wnl.0000000000004905] [Citation(s) in RCA: 25] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2017] [Accepted: 08/24/2017] [Indexed: 11/15/2022] Open
Abstract
OBJECTIVE To evaluate race differences in tissue plasminogen activator (tPA) refusal among eligible patients with acute ischemic stroke (AIS) in Chicago. METHODS Using the Get With The Guidelines-Stroke registry data from 15 primary stroke centers between January 2013 and June 2015, we performed a retrospective analysis of patients with AIS presenting to the emergency department within 4.5 hours from symptom onset. Patient or proxy refusal was captured as a reason for nonadministration of tPA to eligible patients in the registry. We assessed whether tPA refusal differed by race using logistic regression. RESULTS Among 704 tPA-eligible patients with AIS, tPA was administered to 86.2% (black race, 82.5% vs nonblack race, 89.5%; p < 0.001). Fifty-three (7.5%) tPA refusals were documented. Refusal was more common in black vs nonblack patients (10.6% vs 4.8%; p = 0.004). In multivariable analysis, the following were associated with tPA refusal: black race (adjusted odds ratio [OR] 2.5, 95% confidence interval [CI] 1.3-4.6), self-pay status (adjusted OR 3.23, 95% CI 1.2-8.71), prior stroke (adjusted OR 2.11, 95% CI 1.14-3.90), age (adjusted OR 1.04, 95% CI 1.02-1.07), and NIH Stroke Scale score (adjusted OR 0.94, 95% CI 0.90-0.99). CONCLUSIONS Among tPA-eligible patients with AIS in Chicago, over 7% refused tPA. Refusal was more common in black patients and accounted for the apparent lower rates of tPA use in black vs nonblack patients. Further research is needed to understand barriers to consent and overcome race-ethnic disparities in tPA treatment for AIS.
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Affiliation(s)
- Scott J Mendelson
- From the Department of Neurology (S.J.M., S.P.), Department of Emergency Medicine (C.R.), and Center for Healthcare Studies (J.L.H.), Northwestern University Feinberg School of Medicine; Department of Neurologic Sciences and the Rush Alzheimer's Disease Center (N.T.A.), Rush University Medical Center; and American Heart Association (K.O.), Midwest Affiliate, Chicago, IL.
| | - Neelum T Aggarwal
- From the Department of Neurology (S.J.M., S.P.), Department of Emergency Medicine (C.R.), and Center for Healthcare Studies (J.L.H.), Northwestern University Feinberg School of Medicine; Department of Neurologic Sciences and the Rush Alzheimer's Disease Center (N.T.A.), Rush University Medical Center; and American Heart Association (K.O.), Midwest Affiliate, Chicago, IL
| | - Christopher Richards
- From the Department of Neurology (S.J.M., S.P.), Department of Emergency Medicine (C.R.), and Center for Healthcare Studies (J.L.H.), Northwestern University Feinberg School of Medicine; Department of Neurologic Sciences and the Rush Alzheimer's Disease Center (N.T.A.), Rush University Medical Center; and American Heart Association (K.O.), Midwest Affiliate, Chicago, IL
| | - Kathleen O'Neill
- From the Department of Neurology (S.J.M., S.P.), Department of Emergency Medicine (C.R.), and Center for Healthcare Studies (J.L.H.), Northwestern University Feinberg School of Medicine; Department of Neurologic Sciences and the Rush Alzheimer's Disease Center (N.T.A.), Rush University Medical Center; and American Heart Association (K.O.), Midwest Affiliate, Chicago, IL
| | - Jane L Holl
- From the Department of Neurology (S.J.M., S.P.), Department of Emergency Medicine (C.R.), and Center for Healthcare Studies (J.L.H.), Northwestern University Feinberg School of Medicine; Department of Neurologic Sciences and the Rush Alzheimer's Disease Center (N.T.A.), Rush University Medical Center; and American Heart Association (K.O.), Midwest Affiliate, Chicago, IL
| | - Shyam Prabhakaran
- From the Department of Neurology (S.J.M., S.P.), Department of Emergency Medicine (C.R.), and Center for Healthcare Studies (J.L.H.), Northwestern University Feinberg School of Medicine; Department of Neurologic Sciences and the Rush Alzheimer's Disease Center (N.T.A.), Rush University Medical Center; and American Heart Association (K.O.), Midwest Affiliate, Chicago, IL
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Miller JB, Merck LH, Wira CR, Meurer WJ, Schrock JW, Nomura JT, Siket MS, Madsen TE, Wright DW, Panagos PD, Lewandowski C. The Advanced Reperfusion Era: Implications for Emergency Systems of Ischemic Stroke Care. Ann Emerg Med 2017; 69:192-201. [DOI: 10.1016/j.annemergmed.2016.06.042] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2016] [Revised: 06/16/2016] [Accepted: 06/24/2016] [Indexed: 11/30/2022]
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Abstract
Although stroke declined from the third to fifth most common cause of death in the United States, the annual incidence and overall prevalence continue to increase. Since the available US Food and Drug Administration-approved treatment options are time dependent, improving early stroke care may have more of a public health impact than any other phase of care. Timely and efficient stroke treatment should be a priority for emergency department and prehospital providers. This article discusses currently available and emerging treatment options in acute ischemic stroke focusing on the preservation of salvageable brain tissue, minimizing complications, and secondary prevention.
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Affiliation(s)
- Matthew S Siket
- Department of Emergency Medicine, The Warren Alpert Medical School of Brown University, 55 Claverick Street, 2nd Floor, Providence, RI 02903, USA.
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