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Huang AP, Holloway RG. Navigating Neurologic Illness: Skills in Neuropalliative Care for Persons Hospitalized with Neurologic Disease. Semin Neurol 2024. [PMID: 39053504 DOI: 10.1055/s-0044-1788723] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/27/2024]
Abstract
Persons hospitalized for neurologic illness face multidimensional care needs. They can benefit from a palliative care approach that focuses on quality of life for persons with serious illness. We describe neurology provider "skills" to help meet these palliative needs: assessing the patient as a whole; facilitating conversations with patients to connect prognosis to care preferences; navigating neurologic illness to prepare patients and care partners for the future; providing high-quality end-of-life care to promote peace in death; and addressing disparities in care delivery.
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Affiliation(s)
- Andrew P Huang
- Department of Neurology, University of Rochester, Rochester, New York
| | - Robert G Holloway
- Department of Neurology, University of Rochester, Rochester, New York
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2
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Comer AR, Jawed A, Roeder H, Kramer N. The impact of sex and gender on advanced stroke interventions and end-of-life outcomes after stroke. J Stroke Cerebrovasc Dis 2024; 33:107820. [PMID: 38876458 DOI: 10.1016/j.jstrokecerebrovasdis.2024.107820] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2023] [Revised: 06/07/2024] [Accepted: 06/11/2024] [Indexed: 06/16/2024] Open
Abstract
OBJECTIVES In this review, we examine the impact of sex and gender on advanced stroke interventions and end-of-life outcomes after stroke and discuss the current theories, available evidence, and gaps in the literature. METHODS A scoping review of the literature was conducted to determine gender differences on advanced stroke interventions and end-of-life outcomes after stroke. The study team utilized PubMed to conduct a review of the literature and included research studies related to sex, gender, advanced stroke interventions, and end-of-life outcomes after stroke. The PRISMA process for conducting a scoping review was followed. RESULTS This review found that although evidence regarding gender differences in advanced stroke interventions and end-of-life care after stroke is disparate, some gender differences do indeed exist. Women are less likely to receive thrombectomy or alteplase, women are more likely to receive palliative care intervention, hospice, and women experience stroke mortality at higher rates. CONCLUSIONS Gender differences in end-of-life care after stroke are apparent with women experiencing lower rates of life sustaining interventions, and higher rates of mortality, palliative and hospice care. More research is needed to identify variables associated with or responsible for gender differences during advance interventions and end-of-life care after stroke.
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Affiliation(s)
- Amber R Comer
- American Medical Association, Indiana University, United States.
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3
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Schwiddessen R, Malinova V, von Steinbüchel N, Mielke D, Rohde V, von der Brelie C. Spontaneous intracerebral hemorrhage - patients retrospectively consent to fibrinolytic surgery despite poor neurological outcome and reduced health-related quality of life. Neurosurg Rev 2024; 47:268. [PMID: 38862774 PMCID: PMC11166777 DOI: 10.1007/s10143-024-02479-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2023] [Revised: 04/24/2024] [Accepted: 05/20/2024] [Indexed: 06/13/2024]
Abstract
Spontaneous intracerebral hemorrhage (ICH) might lead to devastating consequences. Nonetheless, subjective interpretation of life circumstances might vary. Recent data from ischemic stroke patients show that there might be a paradox between clinically rated neurological outcome and self-reported satisfaction with quality of life. Our hypothesis was that minimally invasive surgically treated ICH patients would still give their consent to stereotactic fibrinolysis despite experiencing relatively poor neurological outcome. In order to better understand the patients' perspective and to enhance insight beyond functional outcome, this is the first study assessing disease-specific health-related quality of life (hrQoL) in ICH after fibrinolytic therapy. We conducted a retrospective analysis of patients with spontaneous ICH treated minimally invasive by stereotactic fibrinolysis. Subsequently, using standardized telephone interviews, we evaluated functional outcome with the modified Rankin Scale (mRS), health-related Quality of Life with the Quality of life after Brain Injury Overall scale (QOLIBRI-OS), and assessed retrospectively if the patients would have given their consent to the treatment. To verify the primary hypothesis that fibrinolytic treated ICH patients would still retrospectively consent to fibrinolytic therapy despite a relatively poor neurological outcome, we conducted a chi-square test to compare good versus poor outcome (mRS) between consenters and non-consenters. To investigate the association between hrQoL (QOLIBRI-OS) and consent, we conducted a Mann-Whitney U-test. Moreover, we did a Spearman correlation to investigate the correlation between functional outcome (mRS) and hrQoL (QOLIBRI-OS). The analysis comprised 63 data sets (35 men, mean age: 66.9 ± 11.8 years, median Hemphill score: 3 [2-3]). Good neurological outcome (mRS 0-3) was achieved in 52% (33/63) of the patients. Patients would have given their consent to surgery retrospectively in 89.7% (52/58). These 52 consenting patients comprised all 33 patients (100%) who achieved good functional outcome and 19 of the 25 patients (76%) who achieved poor neurological outcome (mRS 4-6). The mean QOLIBRI-OS value was 49.55 ± 27.75. A significant association between hrQoL and retrospective consent was found (p = 0.004). This study supports fibrinolytic treatment of ICH even in cases when poor neurological outcome would have to be assumed since subjective perception of deficits could be in contrast with the objectively measured neurological outcome. HrQoL serves as a criterion for success of rtPa lysis therapy in ICH.
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Affiliation(s)
- Regina Schwiddessen
- Department of Neurosurgery, University Medical Center Göttingen, Robert-Koch-Straße 40, 37075, Göttingen, Göttingen, Germany.
| | - Vesna Malinova
- Department of Neurosurgery, University Medical Center Göttingen, Robert-Koch-Straße 40, 37075, Göttingen, Göttingen, Germany
| | - Nicole von Steinbüchel
- Department of Medical Psychology and Medical Sociology, University Medical Center Göttingen, Göttingen, Germany
- Institute of Psychology, University of Innsbruck, Innsbruck, Austria
| | - Dorothee Mielke
- Department of Neurosurgery, University Medical Center Göttingen, Robert-Koch-Straße 40, 37075, Göttingen, Göttingen, Germany
- Department of Neurosurgery, University Medical Center Augsburg, Augsburg, Germany
| | - Veit Rohde
- Department of Neurosurgery, University Medical Center Göttingen, Robert-Koch-Straße 40, 37075, Göttingen, Göttingen, Germany
| | - Christian von der Brelie
- Department of Neurosurgery, University Medical Center Göttingen, Robert-Koch-Straße 40, 37075, Göttingen, Göttingen, Germany
- Department of Neurosurgery and Spine Surgery, Johanniter-Kliniken Bonn, Bonn, Germany
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Lele AV, Moreton EO, Sundararajan J, Blacker SN. Perioperative care of patients with recent stroke undergoing nonemergent, nonneurological, noncardiac, nonvascular surgery: a systematic review and meta-analysis. Curr Opin Anaesthesiol 2024:00001503-990000000-00203. [PMID: 39011660 DOI: 10.1097/aco.0000000000001403] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/17/2024]
Abstract
PURPOSE OF REVIEW To systematically review and perform a meta-analysis of published literature regarding postoperative stroke and mortality in patients with a history of stroke and to provide a framework for preoperative, intraoperative, and postoperative care in an elective setting. RECENT FINDINGS Patients with nonneurological, noncardiac, and nonvascular surgery within three months after stroke have a 153-fold risk, those within 6 months have a 50-fold risk, and those within 12 months have a 20-fold risk of postoperative stroke. There is a 12-fold risk of in-hospital mortality within three months and a three-to-four-fold risk of mortality for more than 12 months after stroke. The risk of stroke and mortality continues to persist years after stroke. Recurrent stroke is common in patients in whom anticoagulation/antiplatelet therapy is discontinued. Stroke and time elapsed after stroke should be included in the preoperative assessment questionnaire, and a stroke-specific risk assessment should be performed before surgical planning is pursued. SUMMARY In patients with a history of a recent stroke, anesthesiology, surgery, and neurology experts should create a shared mental model in which the patient/surrogate decision-maker is informed about the risks and benefits of the proposed surgical procedure; secondary-stroke-prevention medications are reviewed; plans are made for interruptions and resumption; and intraoperative care is individualized to reduce the likelihood of postoperative stroke or death.
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Affiliation(s)
- Abhijit V Lele
- Department of Anesthesiology and Pain Medicine, University of Washington, Harborview Medical Center, Seattle, Washington
| | | | | | - Samuel Neal Blacker
- Department of Anesthesiology, University of North Carolina, Chapel Hill, North Carolina, USA
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5
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Muehlschlegel S. Prognostication in Neurocritical Care. Continuum (Minneap Minn) 2024; 30:878-903. [PMID: 38830074 DOI: 10.1212/con.0000000000001433] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/05/2024]
Abstract
OBJECTIVE This article synthesizes the current literature on prognostication in neurocritical care, identifies existing challenges, and proposes future research directions to reduce variability and enhance scientific and patient-centered approaches to neuroprognostication. LATEST DEVELOPMENTS Patients with severe acute brain injury often lack the capacity to make their own medical decisions, leaving surrogate decision makers responsible for life-or-death choices. These decisions heavily rely on clinicians' prognostication, which is still considered an art because of the previous lack of specific guidelines. Consequently, there is significant variability in neuroprognostication practices. This article examines various aspects of neuroprognostication. It explores the cognitive approach to prognostication, highlights the use of statistical modeling such as Bayesian models and machine learning, emphasizes the importance of clinician-family communication during prognostic disclosures, and proposes shared decision making for more patient-centered care. ESSENTIAL POINTS This article identifies ongoing challenges in the field and emphasizes the need for future research to ameliorate variability in neuroprognostication. By focusing on scientific methodologies and patient-centered approaches, this research aims to provide guidance and tools that may enhance neuroprognostication in neurocritical care.
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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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Kruser JM, Ashana DC, Courtright KR, Kross EK, Neville TH, Rubin E, Schenker Y, Sullivan DR, Thornton JD, Viglianti EM, Costa DK, Creutzfeldt CJ, Detsky ME, Engel HJ, Grover N, Hope AA, Katz JN, Kohn R, Miller AG, Nabozny MJ, Nelson JE, Shanawani H, Stevens JP, Turnbull AE, Weiss CH, Wirpsa MJ, Cox CE. Defining the Time-limited Trial for Patients with Critical Illness: An Official American Thoracic Society Workshop Report. Ann Am Thorac Soc 2024; 21:187-199. [PMID: 38063572 PMCID: PMC10848901 DOI: 10.1513/annalsats.202310-925st] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2023] [Accepted: 12/06/2023] [Indexed: 12/17/2023] Open
Abstract
In critical care, the specific, structured approach to patient care known as a "time-limited trial" has been promoted in the literature to help patients, surrogate decision makers, and clinicians navigate consequential decisions about life-sustaining therapy in the face of uncertainty. Despite promotion of the time-limited trial approach, a lack of consensus about its definition and essential elements prevents optimal clinical use and rigorous evaluation of its impact. The objectives of this American Thoracic Society Workshop Committee were to establish a consensus definition of a time-limited trial in critical care, identify the essential elements for conducting a time-limited trial, and prioritize directions for future work. We achieved these objectives through a structured search of the literature, a modified Delphi process with 100 interdisciplinary and interprofessional stakeholders, and iterative committee discussions. We conclude that a time-limited trial for patients with critical illness is a collaborative plan among clinicians and a patient and/or their surrogate decision makers to use life-sustaining therapy for a defined duration, after which the patient's response to therapy informs the decision to continue care directed toward recovery, transition to care focused exclusively on comfort, or extend the trial's duration. The plan's 16 essential elements follow four sequential phases: consider, plan, support, and reassess. We acknowledge considerable gaps in evidence about the impact of time-limited trials and highlight a concern that if inadequately implemented, time-limited trials may perpetuate unintended harm. Future work is needed to better implement this defined, specific approach to care in practice through a person-centered equity lens and to evaluate its impact on patients, surrogates, and clinicians.
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Kim SH, Jang JH, Kim YZ, Kim KH, Nam TM. Recent Trends in the Withdrawal of Life-Sustaining Treatment in Patients with Acute Cerebrovascular Disease : 2017-2021. J Korean Neurosurg Soc 2024; 67:73-83. [PMID: 37454676 PMCID: PMC10788555 DOI: 10.3340/jkns.2023.0074] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2023] [Revised: 06/07/2023] [Accepted: 07/12/2023] [Indexed: 07/18/2023] Open
Abstract
OBJECTIVE The Act on Life-Sustaining Treatment (LST) decisions for end-of-life patients has been effective since February 2018. An increasing number of patients and their families want to withhold or withdraw from LST when medical futility is expected. This study aimed to investigate the status of the Act on LST decisions for patients with acute cerebrovascular disease at a single hospital. METHODS Between January 2017 and December 2021, 227 patients with acute cerebrovascular diseases, including hemorrhagic stroke (n=184) and ischemic stroke (n=43), died at the hospital. The study period was divided into the periods before and after the Act. RESULTS The duration of hospitalization decreased after the Act was implemented compared to before (15.9±16.1 vs. 11.2±18.6 days, p=0.127). The rate of obtaining consent for the LST plan tended to increase after the Act (139/183 [76.0%] vs. 27/44 [61.4%], p=0.077). Notably, none of the patients made an LST decision independently. Ventilator withdrawal was more frequently performed after the Act than before (52/183 [28.4%] vs. 0/44 [0%], p<0.001). Conversely, the rate of organ donation decreased after the Act was implemented (5/183 [2.7%] vs. 6/44 [13.6%], p=0.008). Refusal to undergo surgery was more common after the Act was implemented than before (87/149 [58.4%] vs. 15/41 [36.6%], p=0.021) among the 190 patients who required surgery. CONCLUSION After the Act on LST decisions was implemented, the rate of LST withdrawal increased in patients with acute cerebrovascular disease. However, the decision to withdraw LST was made by the patient's family rather than the patient themselves. After the execution of the Act, we also observed an increased rate of refusal to undergo surgery and a decreased rate of organ donation. The Act on LST decisions may reduce unnecessary treatments that prolong end-of-life processes without a curative effect. However, the widespread application of this law may also reduce beneficial treatments and contribute to a decline in organ donation.
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Affiliation(s)
- Seung Hwan Kim
- Department of Neurosurgery, Samsung Changwon Hospital, Sungkyunkwan University School of Medicine, Changwon, Korea
| | - Ji Hwan Jang
- Department of Neurosurgery, Samsung Changwon Hospital, Sungkyunkwan University School of Medicine, Changwon, Korea
| | - Young Zoon Kim
- Department of Neurosurgery, Samsung Changwon Hospital, Sungkyunkwan University School of Medicine, Changwon, Korea
| | - Kyu Hong Kim
- Department of Neurosurgery, Samsung Changwon Hospital, Sungkyunkwan University School of Medicine, Changwon, Korea
| | - Taek Min Nam
- Department of Neurosurgery, Samsung Changwon Hospital, Sungkyunkwan University School of Medicine, Changwon, Korea
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9
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Chang VA, Tirschwell DL, Becker KJ, Schubert GB, Longstreth WT, Creutzfeldt CJ. Associations Between Measures of Disability and Quality of Life at Three Months After Stroke. J Palliat Med 2024; 27:18-23. [PMID: 37585623 PMCID: PMC11074430 DOI: 10.1089/jpm.2023.0061] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/28/2023] [Indexed: 08/18/2023] Open
Abstract
Background: The modified Rankin Scale (mRS), which measures degree of disability in daily activities, is the most common outcome measure in stroke research. Quality of life (QoL), however, is impacted by factors other than disability. The goal of this study was to assess the correlation between functional dependence and a more patient-centered QoL measure, the European QoL visual analog scale (EQ VAS). Methods: We reviewed prehospital and hospital records from 11 acute care hospitals in Seattle, Washington (USA) from June 2000 to January 2003 for this cohort study. Patients with a final diagnosis of stroke were contacted three to four months after stroke, and mRS and EQ VAS were assessed. Good QoL was defined as EQ VAS ≥65. Results: Of 760 patients with stroke, 346 were available at three to four months. Most (296, 85.5%) had ischemic stroke. Overall, mRS and QoL were negatively correlated (Spearman's ρ -0.53, p < 0.001). Percentage of good QoL decreased as mRS increased from 0 to 5 (88%, 70%, 52%, 50%, 31%, 20%, respectively, p < 0.001). However, 36% (n = 62) of patients with dependent mRS (3-5, n = 174) reported good QoL, and 30% (n = 52) of patients with independent mRS (0-2, n = 172) reported poor QoL. In multivariable analysis, older age, male gender, and absence of dementia, were associated with good QoL despite dependent mRS; atrial fibrillation was associated with poor QoL despite independent mRS. Conclusions: QoL decreases with increasing mRS, but exceptions exist with good QoL despite high mRS. To provide patient-centered care, clinicians and researchers should avoid equating disability with QoL after stroke.
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Affiliation(s)
- Victoria A. Chang
- Department of Neurology, University of Washington, Seattle, Washington, USA
| | | | - Kyra J. Becker
- Department of Neurology, University of Washington, Seattle, Washington, USA
| | - Glenn B. Schubert
- Department of Neurology, University of Washington, Seattle, Washington, USA
| | - Will T. Longstreth
- Department of Neurology, University of Washington, Seattle, Washington, USA
- Department of Epidemiology, University of Washington, Seattle, Washington, USA
| | - Claire J. Creutzfeldt
- Department of Neurology, University of Washington, Seattle, Washington, USA
- UW Cambia Palliative Care Center of Excellence, University of Washington, Seattle, Washington, USA
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10
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Kreitzer N. Tenecteplase: More Evidence It Should Replace Alteplase for Ischemic Stroke Treatment. Ann Emerg Med 2023; 82:729-731. [PMID: 37598332 DOI: 10.1016/j.annemergmed.2023.07.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2023] [Revised: 07/17/2023] [Accepted: 07/18/2023] [Indexed: 08/21/2023]
Affiliation(s)
- Natalie Kreitzer
- Department of Emergency Medicine, University of Cincinnati, Cincinnati, OH.
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11
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Miranda SP, Morris RS, Rabas M, Creutzfeldt CJ, Cooper Z. Early Shared Decision-Making for Older Adults with Traumatic Brain Injury: Using Time-Limited Trials and Understanding Their Limitations. Neurocrit Care 2023; 39:284-293. [PMID: 37349599 DOI: 10.1007/s12028-023-01764-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2022] [Accepted: 05/11/2023] [Indexed: 06/24/2023]
Abstract
Older adults account for a disproportionate share of the morbidity and mortality after traumatic brain injury (TBI). Predicting functional and cognitive outcomes for individual older adults after TBI is challenging in the acute phase of injury. Given that neurologic recovery is possible and uncertain, life-sustaining therapy may be pursued initially, even if for some, there is a risk of survival to an undesired level of disability or dependence. Experts recommend early conversations about goals of care after TBI, but evidence-based guidelines for these discussions or for the optimal method for communicating prognosis are limited. The time-limited trial (TLT) model may be an effective strategy for managing prognostic uncertainty after TBI. TLTs can provide a framework for early management: specific treatments or procedures are used for a defined period of time while monitoring for an agreed-upon outcome. Outcome measures, including signs of worsening and improvement, are defined at the outset of the trial. In this Viewpoint article, we discuss the use of TLTs for older adults with TBI, their potential benefits, and current challenges to their application. Three main barriers limit the implementation of TLTs in these scenarios: inadequate models for prognostication; cognitive biases faced by clinicians and surrogate decision-makers, which may contribute to prognostic discordance; and ambiguity regarding appropriate endpoints for the TLT. Further study is needed to understand clinician behaviors and surrogate preferences for prognostic communication and how to optimally integrate TLTs into the care of older adults with TBI.
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Affiliation(s)
- Stephen P Miranda
- Department of Neurosurgery, University of Pennsylvania, Philadelphia, PA, USA.
- Perelman Center for Advanced Medicine, 15 South Tower, 3400 Civic Center Blvd, Philadelphia, PA, 19104, USA.
| | - Rachel S Morris
- Department of Surgery, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Mackenzie Rabas
- Department of Surgery, Medical College of Wisconsin, Milwaukee, WI, USA
| | | | - Zara Cooper
- Department of Surgery, Brigham and Women's Hospital, Boston, MA, USA
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12
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Goss A, Ge C, Crawford S, Goostrey K, Buddadhumaruk P, Hough CL, Lo B, Carson S, Steingrub J, White DB, Muehlschlegel S. Prognostic Language in Critical Neurologic Illness: A Multicenter Mixed-Methods Study. Neurology 2023; 101:e558-e569. [PMID: 37290972 PMCID: PMC10401677 DOI: 10.1212/wnl.0000000000207462] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2022] [Accepted: 04/13/2023] [Indexed: 06/10/2023] Open
Abstract
BACKGROUND AND OBJECTIVES There are no evidence-based guidelines for discussing prognosis in critical neurologic illness, but in general, experts recommend that clinicians communicate prognosis using estimates, such as numerical or qualitative expressions of risk. Little is known about how real-world clinicians communicate prognosis in critical neurologic illness. Our primary objective was to characterize prognostic language clinicians used in critical neurologic illness. We additionally explored whether prognostic language differed between prognostic domains (e.g., survival, cognition). METHODS We conducted a multicenter cross-sectional mixed-methods study analyzing deidentified transcripts of audio-recorded clinician-family meetings for patients with neurologic illness requiring intensive care (e.g., intracerebral hemorrhage, traumatic brain injury, severe stroke) from 7 US centers. Two coders assigned codes for prognostic language type and domain of prognosis to each clinician prognostic statement. Prognostic language was coded as probabilistic (estimating the likelihood of an outcome occurring, e.g., "80% survival"; "She'll probably survive") or nonprobabilistic (characterizing outcomes without offering likelihood; e.g., "She may not survive"). We applied univariate and multivariate binomial logistic regression to examine independent associations between prognostic language and domain of prognosis. RESULTS We analyzed 43 clinician-family meetings for 39 patients with 78 surrogates and 27 clinicians. Clinicians made 512 statements about survival (median 0/meeting [interquartile range (IQR) 0-2]), physical function (median 2 [IQR 0-7]), cognition (median 2 [IQR 0-6]), and overall recovery (median 2 [IQR 1-4]). Most statements were nonprobabilistic (316/512 [62%]); 10 of 512 prognostic statements (2%) offered numeric estimates; and 21% (9/43) of family meetings only contained nonprobabilistic language. Compared with statements about cognition, statements about survival (odds ratio [OR] 2.50, 95% CI 1.01-6.18, p = 0.048) and physical function (OR 3.22, 95% 1.77-5.86, p < 0.001) were more frequently probabilistic. Statements about physical function were less likely to be uncertainty-based than statements about cognition (OR 0.34, 95% CI 0.17-0.66, p = 0.002). DISCUSSION Clinicians preferred not to use estimates (either numeric or qualitative) when discussing critical neurologic illness prognosis, especially when they discussed cognitive outcomes. These findings may inform interventions to improve prognostic communication in critical neurologic illness.
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Affiliation(s)
- Adeline Goss
- From the Division of Neurology (A.G.), Department of Internal Medicine, Highland Hospital, Oakland, CA; Department of Neurology (C.G., K.G.), and Tan Chingfang Graduate School of Nursing (S. Crawford), University of Massachusetts Chan Medical School, Worcester; Department of Critical Care Medicine (P.B., D.B.W.), University of Pittsburgh School of Medicine, PA; Division of Pulmonary, Allergy, and Critical Care Medicine (C.L.H.), Department of Medicine, Oregon Health & Science University, Portland; Department of Medicine (B.L.), University of California San Francisco; Division of Pulmonary and Critical Care Medicine (S. Carson), Department of Medicine, University of North Carolina Hospitals, Chapel Hill; Division of Pulmonary Medicine and Critical Care Medicine (J.S.), Department of Internal Medicine, University of Massachusetts Chan Medical School-Baystate, Springfield; and Departments of Neurology, Anesthesia/Critical Care, and Surgery (S.M.), University of Massachusetts Chan Medical School, Worcester
| | - Connie Ge
- From the Division of Neurology (A.G.), Department of Internal Medicine, Highland Hospital, Oakland, CA; Department of Neurology (C.G., K.G.), and Tan Chingfang Graduate School of Nursing (S. Crawford), University of Massachusetts Chan Medical School, Worcester; Department of Critical Care Medicine (P.B., D.B.W.), University of Pittsburgh School of Medicine, PA; Division of Pulmonary, Allergy, and Critical Care Medicine (C.L.H.), Department of Medicine, Oregon Health & Science University, Portland; Department of Medicine (B.L.), University of California San Francisco; Division of Pulmonary and Critical Care Medicine (S. Carson), Department of Medicine, University of North Carolina Hospitals, Chapel Hill; Division of Pulmonary Medicine and Critical Care Medicine (J.S.), Department of Internal Medicine, University of Massachusetts Chan Medical School-Baystate, Springfield; and Departments of Neurology, Anesthesia/Critical Care, and Surgery (S.M.), University of Massachusetts Chan Medical School, Worcester.
| | - Sybil Crawford
- From the Division of Neurology (A.G.), Department of Internal Medicine, Highland Hospital, Oakland, CA; Department of Neurology (C.G., K.G.), and Tan Chingfang Graduate School of Nursing (S. Crawford), University of Massachusetts Chan Medical School, Worcester; Department of Critical Care Medicine (P.B., D.B.W.), University of Pittsburgh School of Medicine, PA; Division of Pulmonary, Allergy, and Critical Care Medicine (C.L.H.), Department of Medicine, Oregon Health & Science University, Portland; Department of Medicine (B.L.), University of California San Francisco; Division of Pulmonary and Critical Care Medicine (S. Carson), Department of Medicine, University of North Carolina Hospitals, Chapel Hill; Division of Pulmonary Medicine and Critical Care Medicine (J.S.), Department of Internal Medicine, University of Massachusetts Chan Medical School-Baystate, Springfield; and Departments of Neurology, Anesthesia/Critical Care, and Surgery (S.M.), University of Massachusetts Chan Medical School, Worcester
| | - Kelsey Goostrey
- From the Division of Neurology (A.G.), Department of Internal Medicine, Highland Hospital, Oakland, CA; Department of Neurology (C.G., K.G.), and Tan Chingfang Graduate School of Nursing (S. Crawford), University of Massachusetts Chan Medical School, Worcester; Department of Critical Care Medicine (P.B., D.B.W.), University of Pittsburgh School of Medicine, PA; Division of Pulmonary, Allergy, and Critical Care Medicine (C.L.H.), Department of Medicine, Oregon Health & Science University, Portland; Department of Medicine (B.L.), University of California San Francisco; Division of Pulmonary and Critical Care Medicine (S. Carson), Department of Medicine, University of North Carolina Hospitals, Chapel Hill; Division of Pulmonary Medicine and Critical Care Medicine (J.S.), Department of Internal Medicine, University of Massachusetts Chan Medical School-Baystate, Springfield; and Departments of Neurology, Anesthesia/Critical Care, and Surgery (S.M.), University of Massachusetts Chan Medical School, Worcester
| | - Praewpannanrai Buddadhumaruk
- From the Division of Neurology (A.G.), Department of Internal Medicine, Highland Hospital, Oakland, CA; Department of Neurology (C.G., K.G.), and Tan Chingfang Graduate School of Nursing (S. Crawford), University of Massachusetts Chan Medical School, Worcester; Department of Critical Care Medicine (P.B., D.B.W.), University of Pittsburgh School of Medicine, PA; Division of Pulmonary, Allergy, and Critical Care Medicine (C.L.H.), Department of Medicine, Oregon Health & Science University, Portland; Department of Medicine (B.L.), University of California San Francisco; Division of Pulmonary and Critical Care Medicine (S. Carson), Department of Medicine, University of North Carolina Hospitals, Chapel Hill; Division of Pulmonary Medicine and Critical Care Medicine (J.S.), Department of Internal Medicine, University of Massachusetts Chan Medical School-Baystate, Springfield; and Departments of Neurology, Anesthesia/Critical Care, and Surgery (S.M.), University of Massachusetts Chan Medical School, Worcester
| | - Catherine L Hough
- From the Division of Neurology (A.G.), Department of Internal Medicine, Highland Hospital, Oakland, CA; Department of Neurology (C.G., K.G.), and Tan Chingfang Graduate School of Nursing (S. Crawford), University of Massachusetts Chan Medical School, Worcester; Department of Critical Care Medicine (P.B., D.B.W.), University of Pittsburgh School of Medicine, PA; Division of Pulmonary, Allergy, and Critical Care Medicine (C.L.H.), Department of Medicine, Oregon Health & Science University, Portland; Department of Medicine (B.L.), University of California San Francisco; Division of Pulmonary and Critical Care Medicine (S. Carson), Department of Medicine, University of North Carolina Hospitals, Chapel Hill; Division of Pulmonary Medicine and Critical Care Medicine (J.S.), Department of Internal Medicine, University of Massachusetts Chan Medical School-Baystate, Springfield; and Departments of Neurology, Anesthesia/Critical Care, and Surgery (S.M.), University of Massachusetts Chan Medical School, Worcester
| | - Bernard Lo
- From the Division of Neurology (A.G.), Department of Internal Medicine, Highland Hospital, Oakland, CA; Department of Neurology (C.G., K.G.), and Tan Chingfang Graduate School of Nursing (S. Crawford), University of Massachusetts Chan Medical School, Worcester; Department of Critical Care Medicine (P.B., D.B.W.), University of Pittsburgh School of Medicine, PA; Division of Pulmonary, Allergy, and Critical Care Medicine (C.L.H.), Department of Medicine, Oregon Health & Science University, Portland; Department of Medicine (B.L.), University of California San Francisco; Division of Pulmonary and Critical Care Medicine (S. Carson), Department of Medicine, University of North Carolina Hospitals, Chapel Hill; Division of Pulmonary Medicine and Critical Care Medicine (J.S.), Department of Internal Medicine, University of Massachusetts Chan Medical School-Baystate, Springfield; and Departments of Neurology, Anesthesia/Critical Care, and Surgery (S.M.), University of Massachusetts Chan Medical School, Worcester
| | - Shannon Carson
- From the Division of Neurology (A.G.), Department of Internal Medicine, Highland Hospital, Oakland, CA; Department of Neurology (C.G., K.G.), and Tan Chingfang Graduate School of Nursing (S. Crawford), University of Massachusetts Chan Medical School, Worcester; Department of Critical Care Medicine (P.B., D.B.W.), University of Pittsburgh School of Medicine, PA; Division of Pulmonary, Allergy, and Critical Care Medicine (C.L.H.), Department of Medicine, Oregon Health & Science University, Portland; Department of Medicine (B.L.), University of California San Francisco; Division of Pulmonary and Critical Care Medicine (S. Carson), Department of Medicine, University of North Carolina Hospitals, Chapel Hill; Division of Pulmonary Medicine and Critical Care Medicine (J.S.), Department of Internal Medicine, University of Massachusetts Chan Medical School-Baystate, Springfield; and Departments of Neurology, Anesthesia/Critical Care, and Surgery (S.M.), University of Massachusetts Chan Medical School, Worcester
| | - Jay Steingrub
- From the Division of Neurology (A.G.), Department of Internal Medicine, Highland Hospital, Oakland, CA; Department of Neurology (C.G., K.G.), and Tan Chingfang Graduate School of Nursing (S. Crawford), University of Massachusetts Chan Medical School, Worcester; Department of Critical Care Medicine (P.B., D.B.W.), University of Pittsburgh School of Medicine, PA; Division of Pulmonary, Allergy, and Critical Care Medicine (C.L.H.), Department of Medicine, Oregon Health & Science University, Portland; Department of Medicine (B.L.), University of California San Francisco; Division of Pulmonary and Critical Care Medicine (S. Carson), Department of Medicine, University of North Carolina Hospitals, Chapel Hill; Division of Pulmonary Medicine and Critical Care Medicine (J.S.), Department of Internal Medicine, University of Massachusetts Chan Medical School-Baystate, Springfield; and Departments of Neurology, Anesthesia/Critical Care, and Surgery (S.M.), University of Massachusetts Chan Medical School, Worcester
| | - Douglas B White
- From the Division of Neurology (A.G.), Department of Internal Medicine, Highland Hospital, Oakland, CA; Department of Neurology (C.G., K.G.), and Tan Chingfang Graduate School of Nursing (S. Crawford), University of Massachusetts Chan Medical School, Worcester; Department of Critical Care Medicine (P.B., D.B.W.), University of Pittsburgh School of Medicine, PA; Division of Pulmonary, Allergy, and Critical Care Medicine (C.L.H.), Department of Medicine, Oregon Health & Science University, Portland; Department of Medicine (B.L.), University of California San Francisco; Division of Pulmonary and Critical Care Medicine (S. Carson), Department of Medicine, University of North Carolina Hospitals, Chapel Hill; Division of Pulmonary Medicine and Critical Care Medicine (J.S.), Department of Internal Medicine, University of Massachusetts Chan Medical School-Baystate, Springfield; and Departments of Neurology, Anesthesia/Critical Care, and Surgery (S.M.), University of Massachusetts Chan Medical School, Worcester
| | - Susanne Muehlschlegel
- From the Division of Neurology (A.G.), Department of Internal Medicine, Highland Hospital, Oakland, CA; Department of Neurology (C.G., K.G.), and Tan Chingfang Graduate School of Nursing (S. Crawford), University of Massachusetts Chan Medical School, Worcester; Department of Critical Care Medicine (P.B., D.B.W.), University of Pittsburgh School of Medicine, PA; Division of Pulmonary, Allergy, and Critical Care Medicine (C.L.H.), Department of Medicine, Oregon Health & Science University, Portland; Department of Medicine (B.L.), University of California San Francisco; Division of Pulmonary and Critical Care Medicine (S. Carson), Department of Medicine, University of North Carolina Hospitals, Chapel Hill; Division of Pulmonary Medicine and Critical Care Medicine (J.S.), Department of Internal Medicine, University of Massachusetts Chan Medical School-Baystate, Springfield; and Departments of Neurology, Anesthesia/Critical Care, and Surgery (S.M.), University of Massachusetts Chan Medical School, Worcester.
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13
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Alkhachroum A, Zhou L, Asdaghi N, Gardener H, Ying H, Gutierrez CM, Manolovitz BM, Samano D, Bass D, Foster D, Sur NB, Rose DZ, Jameson A, Massad N, Kottapally M, Merenda A, Starke RM, O'Phelan K, Romano JG, Claassen J, Sacco RL, Rundek T. Predictors and Temporal Trends of Withdrawal of Life-Sustaining Therapy After Acute Stroke in the Florida Stroke Registry. Crit Care Explor 2023; 5:e0934. [PMID: 37378082 PMCID: PMC10292735 DOI: 10.1097/cce.0000000000000934] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/29/2023] Open
Abstract
Temporal trends and factors associated with the withdrawal of life-sustaining therapy (WLST) after acute stroke are not well determined. DESIGN Observational study (2008-2021). SETTING Florida Stroke Registry (152 hospitals). PATIENTS Acute ischemic stroke (AIS), intracerebral hemorrhage (ICH), and subarachnoid hemorrhage (SAH) patients. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Importance plots were performed to generate the most predictive factors of WLST. Area under the curve (AUC) for the receiver operating curve were generated for the performance of logistic regression (LR) and random forest (RF) models. Regression analysis was applied to evaluate temporal trends. Among 309,393 AIS patients, 47,485 ICH patients, and 16,694 SAH patients; 9%, 28%, and 19% subsequently had WLST. Patients who had WLST were older (77 vs 70 yr), more women (57% vs 49%), White (76% vs 67%), with greater stroke severity on the National Institutes of Health Stroke Scale greater than or equal to 5 (29% vs 19%), more likely hospitalized in comprehensive stroke centers (52% vs 44%), had Medicare insurance (53% vs 44%), and more likely to have impaired level of consciousness (38% vs 12%). Most predictors associated with the decision to WLST in AIS were age, stroke severity, region, insurance status, center type, race, and level of consciousness (RF AUC of 0.93 and LR AUC of 0.85). Predictors in ICH included age, impaired level of consciousness, region, race, insurance status, center type, and prestroke ambulation status (RF AUC of 0.76 and LR AUC of 0.71). Factors in SAH included age, impaired level of consciousness, region, insurance status, race, and stroke center type (RF AUC of 0.82 and LR AUC of 0.72). Despite a decrease in the rates of early WLST (< 2 d) and mortality, the overall rates of WLST remained stable. CONCLUSIONS In acute hospitalized stroke patients in Florida, factors other than brain injury alone contribute to the decision to WLST. Potential predictors not measured in this study include education, culture, faith and beliefs, and patient/family and physician preferences. The overall rates of WLST have not changed in the last 2 decades.
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Affiliation(s)
| | - Lili Zhou
- Department of Neurology, University of Miami, Miami, FL
| | - Negar Asdaghi
- Department of Neurology, University of Miami, Miami, FL
| | | | - Hao Ying
- Department of Neurology, University of Miami, Miami, FL
| | | | | | - Daniel Samano
- Department of Neurology, University of Miami, Miami, FL
| | - Danielle Bass
- Department of Neurology, University of Miami, Miami, FL
| | - Dianne Foster
- Regional Director Quality Improvement, American Heart Association, Dallas, TX
| | - Nicole B Sur
- Department of Neurology, University of Miami, Miami, FL
| | - David Z Rose
- Department of Neurology, Morsani College of Medicine, University of South Florida, Tampa, FL
| | - Angus Jameson
- Department of Emergency Medicine, Pinellas County Emergency Medical Services, Largo, FL
| | - Nina Massad
- Department of Neurology, University of Miami, Miami, FL
| | | | | | - Robert M Starke
- Department of Neurological Surgery, University of Miami, Miami, FL
| | | | - Jose G Romano
- Department of Neurology, University of Miami, Miami, FL
| | - Jan Claassen
- Department of Neurology, Columbia University, New York, NY
| | - Ralph L Sacco
- Department of Neurology, University of Miami, Miami, FL
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14
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Diegoli H, Magalhães PSC, Makdisse MRP, Moro CHC, França PHC, Lange MC, Longo AL. Real-World Populational-Based Quality of Life and Functional Status After Stroke. Value Health Reg Issues 2023; 36:76-82. [PMID: 37054502 DOI: 10.1016/j.vhri.2023.02.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2022] [Revised: 12/24/2022] [Accepted: 02/14/2023] [Indexed: 04/15/2023]
Abstract
OBJECTIVES This study aimed to describe health-related quality of life (HRQoL) 3 months and 1 year after stroke, compare HRQoL between dependent (modified Rankin scale [mRS] 3-5) and independent (mRS 0-2) patients, and identify factors predictive of poor HRQoL. METHODS Patients with a first ischemic stroke or intraparenchymal hemorrhage from the Joinville Stroke Registry were analyzed retrospectively. Using the 5-level version of the EuroQol-5D questionnaire, HRQoL was calculated for all patients 3 months and 1 year after stroke, stratified by mRS score (0-2 or 3-5). One-year HRQoL predictors were examined using univariate and multivariate analyses. RESULTS Three months after a stroke, data from 884 patients were analyzed; 72.8% were categorized as mRS 0-2 and 27.2% as mRS 3-5, and the mean HRQoL was 0.670 ± 0.256. At 1-year follow-up, 705 patients were evaluated; 75% were classified as mRS 0-2 and 25% as mRS 3-5, and the mean HRQoL was 0.71 ± 0.249. An increase in HRQoL was observed between 3 months and 1 year (mean difference 0.024, P < .0001), both in patients with 3-month mRS 0-2 (0.013, P = .027) and mRS 3-5 (0.052, P < .0001). Increasing age, female sex, hypertension, diabetes, and a high mRS were associated with poor HRQoL at 1 year. CONCLUSIONS This study described the HRQoL after a stroke in a Brazilian population. This analysis shows that the mRS was highly associated with HRQoL after stroke. Age, sex, diabetes, and hypertension were also associated with HRQoL, although not independently of mRS.
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Affiliation(s)
| | | | | | - Carla H C Moro
- Joinville Stroke Registry, City Hall of Joinville, Joinville, SC, Brazil
| | - Paulo H C França
- Post-Graduation Program in Health and Environment, University of the Region of Joinville, Joinville, SC, Brazil
| | - Marcos C Lange
- Federal University of Paraná, Clinical Hospital, Curitiba, PR, Brazil
| | - Alexandre L Longo
- Joinville Stroke Registry, City Hall of Joinville, Joinville, SC, Brazil
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15
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Kreitzer N, Murtaugh B, Creutzfeldt C, Fins JJ, Manley G, Sarwal A, Dangayach N. Prognostic humility and ethical dilemmas after severe brain injury: Summary, recommendations, and qualitative analysis of Curing Coma Campaign virtual event proceedings. Front Hum Neurosci 2023; 17:1128656. [PMID: 37063099 PMCID: PMC10102639 DOI: 10.3389/fnhum.2023.1128656] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2022] [Accepted: 03/09/2023] [Indexed: 04/03/2023] Open
Abstract
BackgroundPatients with severe acute brain injuries (SABI) are at risk of living with long-term disability, frequent medical complications and high rates of mortality. Determining an individual patient’s prognosis and conveying this to family members/caregivers can be challenging. We conducted a webinar with experts in neurosurgery, neurocritical care, neuro-palliative care, neuro-ethics, and rehabilitation as part of the Curing Coma Campaign, which is supported by the Neurocritical Care Society. The webinar discussed topics focused on prognostic uncertainty, communicating prognosis to family members/caregivers, gaps within healthcare systems, and research infrastructure as it relates to patients experiencing SABI. The purpose of this manuscript is to describe the themes that emerged from this virtual discussion.MethodsA qualitative analysis of a webinar “Prognostic Humility and Ethical Dilemmas in Acute Brain Injury” was organized as part of the Neurocritical Care Society’s Curing Coma Campaign. A multidisciplinary group of experts was invited as speakers and moderators of the webinar. The content of the webinar was transcribed verbatim. Two qualitative researchers (NK and BM) read and re-read the transcription, and familiarized themselves with the text. The two coders developed and agreed on a code book, independently coded the transcript, and discussed any discrepancies. The transcript was analyzed using inductive thematic analysis of codes and themes that emerged within the expert discussion.ResultsWe coded 168 qualitative excerpts within the transcript. Two main themes were discussed: (1) the concept of prognostic uncertainty in the acute setting, and (2) lack of access to and evidence for quality rehabilitation and specialized continuum of care efforts specific to coma research. Within these two main themes, we found 5 sub-themes, which were broken down into 23 unique codes. The most frequently described code was the need for clinicians to acknowledge our own uncertainties when we discuss prognosis with families, which was mentioned 13 times during the webinar. Several strategies were described for speaking with surrogates of patients who have had a severe brain injury resulting in SABI. We also identified important gaps in the United States health system and in research to improve the care of patients with severe brain injuries.ConclusionAs a result of this webinar and expert discussion, authors identified and analyzed themes related to prognostic uncertainty with SABI. Recommendations were outlined for clinicians who engage with surrogates of patients with SABI to foster informed decisions for their loved one. Finally, recommendations for changes in healthcare systems and research support are provided in order to continue to propel SABI science forward to improve future prognostic certainty.
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Affiliation(s)
- Natalie Kreitzer
- Department of Emergency Medicine, University of Cincinnati, Cincinnati, OH, United States
- *Correspondence: Natalie Kreitzer,
| | - Brooke Murtaugh
- Brain Injury Program Manager, Department of Rehabilitation Programs, Madonna Rehabilitation Hospital, Lincoln, NE, United States
| | | | - Joseph J. Fins
- Division of Medical Ethics, Weill Cornell Medicine, New York, NY, United States
- Yale Law School, New Haven, CT, United States
| | - Geoff Manley
- Department of Neurological Surgery, University of California, San Francisco, San Francisco, CA, United States
| | - Aarti Sarwal
- Department of Neurology, Wake Forest University, Winston-Salem, NC, United States
| | - Neha Dangayach
- Departments of Neurosurgery and Neurology, Icahn School of Medicine at Mount Sinai, New York, NY, United States
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16
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Shlobin NA, Sheldon M, Bernstein M. Ethics of Transitioning from Curative Care to Palliative Care: Potential Conflicts of Interest Using the Example of Neurosurgery. World Neurosurg 2022; 168:139-145. [DOI: 10.1016/j.wneu.2022.10.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2022] [Accepted: 10/02/2022] [Indexed: 11/05/2022]
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17
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Tolsa L, Jones L, Michel P, Borasio GD, Jox RJ, Rutz Voumard R. ‘We Have Guidelines, but We Can Also Be Artists’: Neurologists Discuss Prognostic Uncertainty, Cognitive Biases, and Scoring Tools. Brain Sci 2022; 12:brainsci12111591. [PMID: 36421915 PMCID: PMC9688358 DOI: 10.3390/brainsci12111591] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2022] [Revised: 11/14/2022] [Accepted: 11/18/2022] [Indexed: 11/22/2022] Open
Abstract
Introduction: Ischemic stroke is a leading cause of disability and mortality worldwide. As acute stroke patients often lose decision-making capacity, acute management is fraught with complicated decisions regarding life-sustaining treatment (LST). We aimed to explore (1) the perspectives and experiences of clinicians regarding the use of predictive scores for LST decision making in severe acute stroke, and (2) clinicians’ awareness of their own cognitive biases in this context. Methods: Four focus groups (FGs) were conducted with 21 physicians (13 residents and 8 attending physicians); two FGs in a university hospital and two in a regional hospital in French-speaking Switzerland. Discussions were audio-recorded and transcribed verbatim. Transcripts were analyzed thematically. Two of the four transcripts were double coded to establish coding framework consistency. Results: Participants reported that predictive tools were not routinely used after severe stroke, although most knew about such scores. Scores were reported as being useful in quantifying prognosis, advancing scientific evidence, and minimizing potential biases in decisions. Their use is, however, limited by the following barriers: perception of inaccuracy, general disbelief in scoring, fear of self-fulfilling prophecy, and preference for clinical judgement. Emotional and cognitive biases were common. Emotional biases distort clinicians’ knowledge and are notably: bias of personal values, negative experience, and cultural bias. Cognitive biases, such as availability, confirmation, and anchoring biases, that produce systematic deviations from rational thinking, were also identified. Conclusions: The results highlight opportunities to improve decision making in severe stroke through the promotion of predictive tools, strategies for communicating prognostic uncertainty, and minimizing cognitive biases among clinicians, in order to promote goal-concordant care.
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Affiliation(s)
- Luca Tolsa
- Chair of Geriatric Palliative Care, Lausanne University Hospital and University of Lausanne, 1011 Lausanne, Switzerland
| | - Laura Jones
- Chair of Geriatric Palliative Care, Lausanne University Hospital and University of Lausanne, 1011 Lausanne, Switzerland
| | - Patrik Michel
- Stroke Center, Neurology Service, Lausanne University Hospital and University of Lausanne, 1011 Lausanne, Switzerland
| | - Gian Domenico Borasio
- Palliative and Supportive Care Service, Lausanne University Hospital and University of Lausanne, 1011 Lausanne, Switzerland
| | - Ralf J. Jox
- Chair of Geriatric Palliative Care, Lausanne University Hospital and University of Lausanne, 1011 Lausanne, Switzerland
- Palliative and Supportive Care Service, Lausanne University Hospital and University of Lausanne, 1011 Lausanne, Switzerland
- Institute of Humanities in Medicine, Lausanne University Hospital and University of Lausanne, 1011 Lausanne, Switzerland
| | - Rachel Rutz Voumard
- Palliative and Supportive Care Service, Lausanne University Hospital and University of Lausanne, 1011 Lausanne, Switzerland
- Institute of Humanities in Medicine, Lausanne University Hospital and University of Lausanne, 1011 Lausanne, Switzerland
- Correspondence:
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18
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Muehlschlegel S, Goostrey K, Flahive J, Zhang Q, Pach JJ, Hwang DY. Pilot Randomized Clinical Trial of a Goals-of-Care Decision Aid for Surrogates of Patients With Severe Acute Brain Injury. Neurology 2022; 99:e1446-e1455. [PMID: 35853748 PMCID: PMC9576301 DOI: 10.1212/wnl.0000000000200937] [Citation(s) in RCA: 22] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2021] [Accepted: 05/19/2022] [Indexed: 11/15/2022] Open
Abstract
BACKGROUND AND OBJECTIVES Breakdowns in clinician-family communication in neurologic intensive care units (neuroICUs) are common, particularly for goals-of-care decisions to continue or withdraw life-sustaining treatments while considering long-term prognoses. Shared decision-making interventions (decision aids [DAs]) may prevent this problem and increase patient-centered care, yet none are currently available. We assessed the feasibility, acceptability, and perceived usefulness of a DA for goals-of-care communication with surrogate decision makers for critically ill patients with severe acute brain injury (SABI) after hemispheric acute ischemic stroke, intracerebral hemorrhage, or traumatic brain injury. METHODS We conducted a parallel-arm, unblinded, patient-level randomized, controlled pilot trial at 2 tertiary care US neuroICUs and randomized surrogate participants 1:1 to a tailored paper-based DA provided to surrogates before clinician-family goals-of-care meetings or usual care (no intervention before clinician-family meetings). The primary outcomes were feasibility of deploying the DA (recruitment, participation, and retention), acceptability, and perceived usefulness of the DA among surrogates. Exploratory outcomes included outcome of surrogate goals-of-care decision, code status changes during admission, patients' 3-month functional outcome, and surrogates' 3-month validated psychological outcomes. RESULTS We approached 83 surrogates of 58 patients and enrolled 66 surrogates of 41 patients (80% consent rate). Of 66 surrogates, 45 remained in the study at 3 months (68% retention). Of the 33 surrogates randomized to intervention, 27 were able to receive the DA, and 25 subsequently read the DA (93% participation). Eighty-two percent rated the DA's acceptability as good or excellent (median acceptability score 2 [IQR 2-3]); 96% found it useful for goals-of-care decision making. In the DA group, there was a trend toward fewer comfort care decisions (27% vs 56%, p = 0.1) and fewer code status changes (no change, 73% vs 44%, p = 0.02). At 3 months, fewer patients in the DA group had died (33% vs 69%, p = 0.05; median Glasgow Outcome Scale 3 vs1, p = 0.05). Regardless of intervention, 3-month psychological outcomes were significantly worse among surrogates who had chosen continuation of care. DISCUSSION A goals-of-care DA to support ICU shared decision making for patients with SABI is feasible to deploy and well perceived by surrogates. A larger trial is feasible to conduct, although surrogates who select continuation of care deserve additional psychosocial support. CLINICAL TRIALS REGISTRATION Clinicaltrials.gov NCT03833375. CLASSIFICATION OF EVIDENCE This study provides Class IV evidence that the use of a DA explaining the goals-of-care decision and the treatment options is acceptable and useful to surrogates of incapacitated critically ill patients with ischemic stroke, intracerebral hemorrhage, or traumatic brain injury.
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Affiliation(s)
- Susanne Muehlschlegel
- From the Departments of Neurology (S.M., K.G.), Anesthesiology (S.M.), Surgery (S.M.), and Population and Quantitative Health Sciences (J.F.), University of Massachusetts Chan Medical School, Worcester; and Division of Neurocritical Care and Emergency Neurology (Q.Z., J.J.P., D.Y.H.), Department of Neurology, Yale School of Medicine, New Haven, CT.
| | - Kelsey Goostrey
- From the Departments of Neurology (S.M., K.G.), Anesthesiology (S.M.), Surgery (S.M.), and Population and Quantitative Health Sciences (J.F.), University of Massachusetts Chan Medical School, Worcester; and Division of Neurocritical Care and Emergency Neurology (Q.Z., J.J.P., D.Y.H.), Department of Neurology, Yale School of Medicine, New Haven, CT
| | - Julie Flahive
- From the Departments of Neurology (S.M., K.G.), Anesthesiology (S.M.), Surgery (S.M.), and Population and Quantitative Health Sciences (J.F.), University of Massachusetts Chan Medical School, Worcester; and Division of Neurocritical Care and Emergency Neurology (Q.Z., J.J.P., D.Y.H.), Department of Neurology, Yale School of Medicine, New Haven, CT
| | - Qiang Zhang
- From the Departments of Neurology (S.M., K.G.), Anesthesiology (S.M.), Surgery (S.M.), and Population and Quantitative Health Sciences (J.F.), University of Massachusetts Chan Medical School, Worcester; and Division of Neurocritical Care and Emergency Neurology (Q.Z., J.J.P., D.Y.H.), Department of Neurology, Yale School of Medicine, New Haven, CT
| | - Jolanta J Pach
- From the Departments of Neurology (S.M., K.G.), Anesthesiology (S.M.), Surgery (S.M.), and Population and Quantitative Health Sciences (J.F.), University of Massachusetts Chan Medical School, Worcester; and Division of Neurocritical Care and Emergency Neurology (Q.Z., J.J.P., D.Y.H.), Department of Neurology, Yale School of Medicine, New Haven, CT
| | - David Y Hwang
- From the Departments of Neurology (S.M., K.G.), Anesthesiology (S.M.), Surgery (S.M.), and Population and Quantitative Health Sciences (J.F.), University of Massachusetts Chan Medical School, Worcester; and Division of Neurocritical Care and Emergency Neurology (Q.Z., J.J.P., D.Y.H.), Department of Neurology, Yale School of Medicine, New Haven, CT
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19
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Shlobin NA, Clark JR, Campbell JM, Bernstein M, Jahromi BS, Potts MB. Ethical Considerations in Surgical Decompression for Stroke. Stroke 2022; 53:2673-2682. [PMID: 35703095 DOI: 10.1161/strokeaha.121.038493] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Stroke is a major cause of morbidity and mortality. Neurosurgical decompression is often considered for the treatment of malignant infarcts and intraparenchymal hemorrhages, but this treatment can be frought with ethical dilemmas. In this article, the authors outline the primary principles of bioethics and their application to stroke care, provide an overview of key ethical issues and special situations in the neurosurgical management of stroke, and highlight methods to improve ethical decision-making for patients with stroke. Understanding these ethical principles is essential for stroke care teams to deliver appropriate, timely, and ethical care to patients with stroke.
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Affiliation(s)
- Nathan A Shlobin
- Department of Neurological Surgery, Northwestern University Feinberg School of Medicine, Chicago, IL. (N.A.S., J.R.C., B.S.J., M.B.P.)
| | - Jeffrey R Clark
- Department of Neurological Surgery, Northwestern University Feinberg School of Medicine, Chicago, IL. (N.A.S., J.R.C., B.S.J., M.B.P.)
| | | | - Mark Bernstein
- Division of Neurosurgery, Department of Surgery, University of Toronto, University Health Network, Ontario, Canada (M.B.)
| | - Babak S Jahromi
- Department of Neurological Surgery, Northwestern University Feinberg School of Medicine, Chicago, IL. (N.A.S., J.R.C., B.S.J., M.B.P.).,Department of Radiology, Northwestern University Feinberg School of Medicine, Chicago, IL. (B.S.J., M.B.P.).,Department of Neurology, Northwestern University Feinberg School of Medicine, Chicago, IL. (B.S.J., M.B.P.)
| | - Matthew B Potts
- Department of Neurological Surgery, Northwestern University Feinberg School of Medicine, Chicago, IL. (N.A.S., J.R.C., B.S.J., M.B.P.).,Department of Radiology, Northwestern University Feinberg School of Medicine, Chicago, IL. (B.S.J., M.B.P.).,Department of Neurology, Northwestern University Feinberg School of Medicine, Chicago, IL. (B.S.J., M.B.P.)
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Goostrey K, Muehlschlegel S. Prognostication and shared decision making in neurocritical care. BMJ 2022; 377:e060154. [PMID: 35696329 DOI: 10.1136/bmj-2021-060154] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
Prognostication is crucial in the neurological intensive care unit (neuroICU). Patients with severe acute brain injury (SABI) are unable to make their own decisions because of the insult itself or sedation needs. Surrogate decision makers, usually family members, must make decisions on the patient's behalf. However, many are unprepared for their role as surrogates owing to the sudden and unexpected nature of SABI. Surrogates rely on clinicians in the neuroICU to provide them with an outlook (prognosis) with which to make substituted judgments and decide on treatments and goals of care on behalf of the patient. Therefore, how a prognostic estimate is derived, and then communicated, is extremely important. Prognostication in the neuroICU is highly variable between clinicians and institutions, and evidence based guidelines are lacking. Shared decision making (SDM), where surrogates and clinicians arrive together at an individualized decision based on patient values and preferences, has been proposed as an opportunity to improve clinician-family communication and ensure that patients receive treatments they would choose. This review outlines the importance and current challenges of prognostication in the neuroICU and how prognostication and SDM intersect, based on relevant research and expert opinion.
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Affiliation(s)
- Kelsey Goostrey
- Department of neurology, University of Massachusetts Chan Medical School, Worcester, MA, USA
| | - Susanne Muehlschlegel
- Department of neurology, University of Massachusetts Chan Medical School, Worcester, MA, USA
- Department of anesthesiology/critical care, University of Massachusetts Chan Medical School, Worcester, MA, USA
- Department of surgery, University of Massachusetts Chan Medical School, Worcester, MA, USA
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21
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Alkhachroum A, Bustillo AJ, Asdaghi N, Ying H, Marulanda-Londono E, Gutierrez CM, Samano D, Sobczak E, Foster D, Kottapally M, Merenda A, Koch S, Romano JG, O'Phelan K, Claassen J, Sacco RL, Rundek T. Association of Acute Alteration of Consciousness in Patients With Acute Ischemic Stroke With Outcomes and Early Withdrawal of Care. Neurology 2022; 98:e1470-e1478. [PMID: 35169010 PMCID: PMC8992606 DOI: 10.1212/wnl.0000000000200018] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2021] [Accepted: 01/03/2022] [Indexed: 01/01/2023] Open
Abstract
BACKGROUND AND OBJECTIVES Early consciousness disorder (ECD) after acute ischemic stroke (AIS) is understudied. ECD may influence outcomes and the decision to withhold or withdraw life-sustaining treatment. METHODS We studied patients with AIS from 2010 to 2019 across 122 hospitals participating in the Florida Stroke Registry. We studied the effect of ECD on in-hospital mortality, withholding or withdrawal of life-sustaining treatment (WLST), ambulation status on discharge, hospital length of stay, and discharge disposition. RESULTS Of 238,989 patients with AIS, 32,861 (14%) had ECD at stroke presentation. Overall, average age was 72 years (Q1 61, Q3 82), 49% were women, 63% were White, 18% were Black, and 14% were Hispanic. Compared to patients without ECD, patients with ECD were older (77 vs 72 years), were more often female (54% vs 48%), had more comorbidities, had greater stroke severity as assessed by the National Institutes of Health Stroke Scale (score ≥5 49% vs 27%), had higher WLST rates (21% vs 6%), and had greater in-hospital mortality (9% vs 3%). Using adjusted models accounting for basic characteristics, patients with ECD had greater in-hospital mortality (odds ratio [OR] 2.23, 95% CI 1.98-2.51), had longer hospitalization (OR 1.37, 95% CI 1.33-1.44), were less likely to be discharged home or to rehabilitation (OR 0.54, 95% CI 0.52-0.57), and were less likely to ambulate independently (OR 0.61, 95% CI 0.57-0.64). WLST significantly mediated the effect of ECD on mortality (mediation effect 265; 95% CI 217-314). In temporal trend analysis, we found a significant decrease in early WLST (<2 days) (R2 0.7, p = 0.002) and an increase in late WLST (≥2 days) (R2 0.7, p = 0.004). DISCUSSION In this large prospective multicenter stroke registry, patients with AIS presenting with ECD had greater mortality and worse discharge outcomes. Mortality was largely influenced by the WLST decision.
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Affiliation(s)
- Ayham Alkhachroum
- From the Department of Neurology (A.A., A.J.B., N.A., H.Y., E.M.-L., C.M.G., D.S., E.S., M.K., A.M., S.K., J.G.R., K.O., R.L.S., T.R.), University of Miami; Department of Neurology (A.A., A.J.B., N.A., H.Y., E.M.-L., C.M.G., D.S., E.S., M.K., A.M., S.K., J.G.R., K.O., R.L.S., T.R.), Jackson Memorial Hospital, Miami, FL; Regional Director Quality Improvement (D.F.), American Heart Association, Marietta, GA; and Department of Neurology (J.C.), Columbia University, New York, NY
| | - Antonio J Bustillo
- From the Department of Neurology (A.A., A.J.B., N.A., H.Y., E.M.-L., C.M.G., D.S., E.S., M.K., A.M., S.K., J.G.R., K.O., R.L.S., T.R.), University of Miami; Department of Neurology (A.A., A.J.B., N.A., H.Y., E.M.-L., C.M.G., D.S., E.S., M.K., A.M., S.K., J.G.R., K.O., R.L.S., T.R.), Jackson Memorial Hospital, Miami, FL; Regional Director Quality Improvement (D.F.), American Heart Association, Marietta, GA; and Department of Neurology (J.C.), Columbia University, New York, NY
| | - Negar Asdaghi
- From the Department of Neurology (A.A., A.J.B., N.A., H.Y., E.M.-L., C.M.G., D.S., E.S., M.K., A.M., S.K., J.G.R., K.O., R.L.S., T.R.), University of Miami; Department of Neurology (A.A., A.J.B., N.A., H.Y., E.M.-L., C.M.G., D.S., E.S., M.K., A.M., S.K., J.G.R., K.O., R.L.S., T.R.), Jackson Memorial Hospital, Miami, FL; Regional Director Quality Improvement (D.F.), American Heart Association, Marietta, GA; and Department of Neurology (J.C.), Columbia University, New York, NY
| | - Hao Ying
- From the Department of Neurology (A.A., A.J.B., N.A., H.Y., E.M.-L., C.M.G., D.S., E.S., M.K., A.M., S.K., J.G.R., K.O., R.L.S., T.R.), University of Miami; Department of Neurology (A.A., A.J.B., N.A., H.Y., E.M.-L., C.M.G., D.S., E.S., M.K., A.M., S.K., J.G.R., K.O., R.L.S., T.R.), Jackson Memorial Hospital, Miami, FL; Regional Director Quality Improvement (D.F.), American Heart Association, Marietta, GA; and Department of Neurology (J.C.), Columbia University, New York, NY
| | - Erika Marulanda-Londono
- From the Department of Neurology (A.A., A.J.B., N.A., H.Y., E.M.-L., C.M.G., D.S., E.S., M.K., A.M., S.K., J.G.R., K.O., R.L.S., T.R.), University of Miami; Department of Neurology (A.A., A.J.B., N.A., H.Y., E.M.-L., C.M.G., D.S., E.S., M.K., A.M., S.K., J.G.R., K.O., R.L.S., T.R.), Jackson Memorial Hospital, Miami, FL; Regional Director Quality Improvement (D.F.), American Heart Association, Marietta, GA; and Department of Neurology (J.C.), Columbia University, New York, NY
| | - Carolina M Gutierrez
- From the Department of Neurology (A.A., A.J.B., N.A., H.Y., E.M.-L., C.M.G., D.S., E.S., M.K., A.M., S.K., J.G.R., K.O., R.L.S., T.R.), University of Miami; Department of Neurology (A.A., A.J.B., N.A., H.Y., E.M.-L., C.M.G., D.S., E.S., M.K., A.M., S.K., J.G.R., K.O., R.L.S., T.R.), Jackson Memorial Hospital, Miami, FL; Regional Director Quality Improvement (D.F.), American Heart Association, Marietta, GA; and Department of Neurology (J.C.), Columbia University, New York, NY
| | - Daniel Samano
- From the Department of Neurology (A.A., A.J.B., N.A., H.Y., E.M.-L., C.M.G., D.S., E.S., M.K., A.M., S.K., J.G.R., K.O., R.L.S., T.R.), University of Miami; Department of Neurology (A.A., A.J.B., N.A., H.Y., E.M.-L., C.M.G., D.S., E.S., M.K., A.M., S.K., J.G.R., K.O., R.L.S., T.R.), Jackson Memorial Hospital, Miami, FL; Regional Director Quality Improvement (D.F.), American Heart Association, Marietta, GA; and Department of Neurology (J.C.), Columbia University, New York, NY
| | - Evie Sobczak
- From the Department of Neurology (A.A., A.J.B., N.A., H.Y., E.M.-L., C.M.G., D.S., E.S., M.K., A.M., S.K., J.G.R., K.O., R.L.S., T.R.), University of Miami; Department of Neurology (A.A., A.J.B., N.A., H.Y., E.M.-L., C.M.G., D.S., E.S., M.K., A.M., S.K., J.G.R., K.O., R.L.S., T.R.), Jackson Memorial Hospital, Miami, FL; Regional Director Quality Improvement (D.F.), American Heart Association, Marietta, GA; and Department of Neurology (J.C.), Columbia University, New York, NY
| | - Dianne Foster
- From the Department of Neurology (A.A., A.J.B., N.A., H.Y., E.M.-L., C.M.G., D.S., E.S., M.K., A.M., S.K., J.G.R., K.O., R.L.S., T.R.), University of Miami; Department of Neurology (A.A., A.J.B., N.A., H.Y., E.M.-L., C.M.G., D.S., E.S., M.K., A.M., S.K., J.G.R., K.O., R.L.S., T.R.), Jackson Memorial Hospital, Miami, FL; Regional Director Quality Improvement (D.F.), American Heart Association, Marietta, GA; and Department of Neurology (J.C.), Columbia University, New York, NY
| | - Mohan Kottapally
- From the Department of Neurology (A.A., A.J.B., N.A., H.Y., E.M.-L., C.M.G., D.S., E.S., M.K., A.M., S.K., J.G.R., K.O., R.L.S., T.R.), University of Miami; Department of Neurology (A.A., A.J.B., N.A., H.Y., E.M.-L., C.M.G., D.S., E.S., M.K., A.M., S.K., J.G.R., K.O., R.L.S., T.R.), Jackson Memorial Hospital, Miami, FL; Regional Director Quality Improvement (D.F.), American Heart Association, Marietta, GA; and Department of Neurology (J.C.), Columbia University, New York, NY
| | - Amedeo Merenda
- From the Department of Neurology (A.A., A.J.B., N.A., H.Y., E.M.-L., C.M.G., D.S., E.S., M.K., A.M., S.K., J.G.R., K.O., R.L.S., T.R.), University of Miami; Department of Neurology (A.A., A.J.B., N.A., H.Y., E.M.-L., C.M.G., D.S., E.S., M.K., A.M., S.K., J.G.R., K.O., R.L.S., T.R.), Jackson Memorial Hospital, Miami, FL; Regional Director Quality Improvement (D.F.), American Heart Association, Marietta, GA; and Department of Neurology (J.C.), Columbia University, New York, NY
| | - Sebastian Koch
- From the Department of Neurology (A.A., A.J.B., N.A., H.Y., E.M.-L., C.M.G., D.S., E.S., M.K., A.M., S.K., J.G.R., K.O., R.L.S., T.R.), University of Miami; Department of Neurology (A.A., A.J.B., N.A., H.Y., E.M.-L., C.M.G., D.S., E.S., M.K., A.M., S.K., J.G.R., K.O., R.L.S., T.R.), Jackson Memorial Hospital, Miami, FL; Regional Director Quality Improvement (D.F.), American Heart Association, Marietta, GA; and Department of Neurology (J.C.), Columbia University, New York, NY
| | - Jose G Romano
- From the Department of Neurology (A.A., A.J.B., N.A., H.Y., E.M.-L., C.M.G., D.S., E.S., M.K., A.M., S.K., J.G.R., K.O., R.L.S., T.R.), University of Miami; Department of Neurology (A.A., A.J.B., N.A., H.Y., E.M.-L., C.M.G., D.S., E.S., M.K., A.M., S.K., J.G.R., K.O., R.L.S., T.R.), Jackson Memorial Hospital, Miami, FL; Regional Director Quality Improvement (D.F.), American Heart Association, Marietta, GA; and Department of Neurology (J.C.), Columbia University, New York, NY
| | - Kristine O'Phelan
- From the Department of Neurology (A.A., A.J.B., N.A., H.Y., E.M.-L., C.M.G., D.S., E.S., M.K., A.M., S.K., J.G.R., K.O., R.L.S., T.R.), University of Miami; Department of Neurology (A.A., A.J.B., N.A., H.Y., E.M.-L., C.M.G., D.S., E.S., M.K., A.M., S.K., J.G.R., K.O., R.L.S., T.R.), Jackson Memorial Hospital, Miami, FL; Regional Director Quality Improvement (D.F.), American Heart Association, Marietta, GA; and Department of Neurology (J.C.), Columbia University, New York, NY
| | - Jan Claassen
- From the Department of Neurology (A.A., A.J.B., N.A., H.Y., E.M.-L., C.M.G., D.S., E.S., M.K., A.M., S.K., J.G.R., K.O., R.L.S., T.R.), University of Miami; Department of Neurology (A.A., A.J.B., N.A., H.Y., E.M.-L., C.M.G., D.S., E.S., M.K., A.M., S.K., J.G.R., K.O., R.L.S., T.R.), Jackson Memorial Hospital, Miami, FL; Regional Director Quality Improvement (D.F.), American Heart Association, Marietta, GA; and Department of Neurology (J.C.), Columbia University, New York, NY
| | - Ralph L Sacco
- From the Department of Neurology (A.A., A.J.B., N.A., H.Y., E.M.-L., C.M.G., D.S., E.S., M.K., A.M., S.K., J.G.R., K.O., R.L.S., T.R.), University of Miami; Department of Neurology (A.A., A.J.B., N.A., H.Y., E.M.-L., C.M.G., D.S., E.S., M.K., A.M., S.K., J.G.R., K.O., R.L.S., T.R.), Jackson Memorial Hospital, Miami, FL; Regional Director Quality Improvement (D.F.), American Heart Association, Marietta, GA; and Department of Neurology (J.C.), Columbia University, New York, NY
| | - Tatjana Rundek
- From the Department of Neurology (A.A., A.J.B., N.A., H.Y., E.M.-L., C.M.G., D.S., E.S., M.K., A.M., S.K., J.G.R., K.O., R.L.S., T.R.), University of Miami; Department of Neurology (A.A., A.J.B., N.A., H.Y., E.M.-L., C.M.G., D.S., E.S., M.K., A.M., S.K., J.G.R., K.O., R.L.S., T.R.), Jackson Memorial Hospital, Miami, FL; Regional Director Quality Improvement (D.F.), American Heart Association, Marietta, GA; and Department of Neurology (J.C.), Columbia University, New York, NY
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22
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Finley Caulfield A, Mlynash M, Eyngorn I, Lansberg MG, Afjei A, Venkatasubramanian C, Buckwalter MS, Hirsch KG. Prognostication of ICU Patients by Providers with and without Neurocritical Care Training. Neurocrit Care 2022; 37:190-199. [PMID: 35314970 DOI: 10.1007/s12028-022-01467-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2021] [Accepted: 02/04/2022] [Indexed: 12/21/2022]
Abstract
BACKGROUND Predictions of functional outcome in neurocritical care (NCC) patients impact care decisions. This study compared the predictive values (PVs) of good and poor functional outcome among health care providers with and without NCC training. METHODS Consecutive patients who were intubated for ≥ 72 h with primary neurological illness or neurological complications were prospectively enrolled and followed for 6-month functional outcome. Medical intensive care unit (MICU) attendings, NCC attendings, residents (RES), and nurses (RN) predicted 6-month functional outcome on the modified Rankin scale (mRS). The primary objective was to compare these four groups' PVs of a good (mRS score 0-3) and a poor (mRS score 4-6) outcome prediction. RESULTS Two hundred eighty-nine patients were enrolled. One hundred seventy-six had mRS scores predicted by a provider from each group and were included in the primary outcome analysis. At 6 months, 54 (31%) patients had good outcome and 122 (69%) had poor outcome. Compared with other providers, NCC attendings expected better outcomes (p < 0.001). Consequently, the PV of a poor outcome prediction by NCC attendings was higher (96% [95% confidence interval [CI] 89-99%]) than that by MICU attendings (88% [95% CI 80-93%]), RES (82% [95% CI 74-88%]), and RN (85% [95% CI 77-91%]) (p = 0.047, 0.002, and 0.012, respectively). When patients who had withdrawal of life-sustaining therapy (n = 67) were excluded, NCC attendings remained better at predicting poor outcome (NCC 90% [95% CI 75-97%] vs. MICU 73% [95% CI 59-84%], p = 0.064). The PV of a good outcome prediction was similar among groups (MICU 65% [95% CI 52-76%], NCC 63% [95% CI 51-73%], RES 71% [95% CI 55-84%], and RN 64% [95% CI 50-76%]). CONCLUSIONS Neurointensivists expected better outcomes than other providers and were better at predicting poor functional outcomes. The PV of a good outcome prediction was modest among all providers.
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Affiliation(s)
- Anna Finley Caulfield
- Department of Neurology and Neurological Sciences, Stanford Stroke Center, Stanford University, 453 Quarry Rd, MC 5235, Palo Alto, CA, USA.
| | - Michael Mlynash
- Department of Neurology and Neurological Sciences, Stanford Stroke Center, Stanford University, 453 Quarry Rd, MC 5235, Palo Alto, CA, USA
| | - Irina Eyngorn
- Department of Neurology and Neurological Sciences, Stanford Stroke Center, Stanford University, 453 Quarry Rd, MC 5235, Palo Alto, CA, USA
| | - Maarten G Lansberg
- Department of Neurology and Neurological Sciences, Stanford Stroke Center, Stanford University, 453 Quarry Rd, MC 5235, Palo Alto, CA, USA
| | - Anousheh Afjei
- Department of Neurology and Neurological Sciences, Stanford Stroke Center, Stanford University, 453 Quarry Rd, MC 5235, Palo Alto, CA, USA
| | - Chitra Venkatasubramanian
- Department of Neurology and Neurological Sciences, Stanford Stroke Center, Stanford University, 453 Quarry Rd, MC 5235, Palo Alto, CA, USA
| | - Marion S Buckwalter
- Department of Neurology and Neurological Sciences, Stanford Stroke Center, Stanford University, 453 Quarry Rd, MC 5235, Palo Alto, CA, USA
| | - Karen G Hirsch
- Department of Neurology and Neurological Sciences, Stanford Stroke Center, Stanford University, 453 Quarry Rd, MC 5235, Palo Alto, CA, USA
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The Experiences and Needs of Families of Comatose Patients After Cardiac Arrest and Severe Neurotrauma: The Perspectives of National Key Stakeholders During a National Institutes of Health–Funded Workshop. Crit Care Explor 2022; 4:e0648. [PMID: 35265851 PMCID: PMC8901216 DOI: 10.1097/cce.0000000000000648] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
Severe acute brain injury (SABI) from cardiac arrest and traumatic brain injury happens suddenly and unexpectedly, carrying high potential for lifelong disability with substantial prognostic uncertainty. Comprehensive assessments of family experiences and support needs after SABI are lacking. Our objective is to elicit “on-the-ground” perspectives about the experiences and needs of families of patients with SABI.
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24
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Han Q, Li M, Su D, Fu A, Li L, Chen T. Development and validation of a 30-day death nomogram in patients with spontaneous cerebral hemorrhage: a retrospective cohort study. Acta Neurol Belg 2022; 122:67-74. [PMID: 33566335 DOI: 10.1007/s13760-021-01617-1] [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: 09/06/2020] [Accepted: 01/28/2021] [Indexed: 11/25/2022]
Abstract
The purpose of this study was to establish and validate a nomogram to estimate the 30-day probability of death in patients with spontaneous cerebral hemorrhage. From January 2015 to December 2017, a cohort of 450 patients with clinically diagnosed cerebral hemorrhage was collected for model development. The minimum absolute contraction and the selection operator (lasso) regression model were used to select the strongest prediction of patients with cerebral hemorrhage. Discrimination and calibration were used to evaluate the performance of the resulting nomogram. After internal validation, the nomogram was further assessed in a different cohort containing 148 consecutive subjects examined between January 2018 and December 2018. The nomogram included five predictors from the lasso regression analysis, including: Glasgow coma scale (GCS), hematoma location, hematoma volume, white blood cells, and D-dimer. Internal verification showed that the model had good discrimination, (the area under the curve is 0.955), and good calibration [unreliability (U) statistic, p = 0.739]. The nomogram still showed good discrimination (area under the curve = 0.888) and good calibration [U statistic, p = 0.926] in the verification cohort data. Decision curve analysis showed that the prediction nomogram was clinically useful. The current study delineates a predictive nomogram combining clinical and imaging features, which can help identify patients who may die of cerebral hemorrhage.
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Affiliation(s)
- Qian Han
- Department of Neurosurgery, North China University of Science and Technology Affiliated Hospital, Tangshan, 063000, Hebei, China
| | - Mei Li
- Department of Neurosurgery, North China University of Science and Technology Affiliated Hospital, Tangshan, 063000, Hebei, China
| | - Dongpo Su
- Department of Neurosurgery, North China University of Science and Technology Affiliated Hospital, Tangshan, 063000, Hebei, China
| | - Aijun Fu
- Department of Neurosurgery, North China University of Science and Technology Affiliated Hospital, Tangshan, 063000, Hebei, China
| | - Lin Li
- Department of Neurosurgery, North China University of Science and Technology Affiliated Hospital, Tangshan, 063000, Hebei, China
| | - Tong Chen
- Department of Neurosurgery, North China University of Science and Technology Affiliated Hospital, Tangshan, 063000, Hebei, China.
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25
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De Georgia M. The intersection of prognostication and code status in patients with severe brain injury. J Crit Care 2022; 69:153997. [PMID: 35114602 DOI: 10.1016/j.jcrc.2022.153997] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2021] [Revised: 12/27/2021] [Accepted: 01/18/2022] [Indexed: 11/16/2022]
Abstract
Accurately estimating the prognosis of brain injury patients can be difficult, especially early in their course. Prognostication is important because it largely determines the care level we provide, from aggressive treatment for patients we predict could have a good outcome to withdrawal of treatment for those we expect will have a poor outcome. Accurate prognostication is required for ethical decision-making. However, several studies have shown that prognostication is frequently inaccurate and variable. Overly optimistic prognostication can lead to false hope and futile care. Overly pessimistic prognostication can lead to therapeutic nihilism. Overlapping is the powerful effect that cognitive biases, in particular code status, can play in shaping our perceptions and the care level we provide. The presence of Do Not Resuscitate orders has been shown to be associated with increased mortality. Based on a comprehensive search of peer-reviewed journals using a wide range of key terms, including prognostication, critical illness, brain injury, cognitive bias, and code status, the following is a review of prognostic accuracy and the effect of code status on outcome. Because withdrawal of treatment is the most common cause of death in the ICU, a clearer understanding of this intersection of prognostication and code status is needed.
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Affiliation(s)
- Michael De Georgia
- University Hospitals Cleveland Medical Center, Cleveland, OH, United States of America.
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26
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Appelros P, Svensson E, Heidenreich K, Svantesson M. Ethical issues in stroke thrombolysis revisited. Acta Neurol Scand 2021; 144:611-615. [PMID: 34725820 DOI: 10.1111/ane.13530] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2021] [Accepted: 08/30/2021] [Indexed: 11/27/2022]
Affiliation(s)
- Peter Appelros
- Faculty of Medicine and Health University Health Care Research CenterÖrebro University Örebro Sweden
| | - Elisabeth Svensson
- Faculty of Medicine and Health University Health Care Research CenterÖrebro University Örebro Sweden
| | - Kaja Heidenreich
- Faculty of Medicine and Health University Health Care Research CenterÖrebro University Örebro Sweden
| | - Mia Svantesson
- Faculty of Medicine and Health University Health Care Research CenterÖrebro University Örebro Sweden
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27
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Abstract
The palliative care needs of inpatients with neurologic illness are varied, depending on diagnosis, acuity of illness, available treatment options, prognosis, and goals of care. Inpatient neurologists ought to be proficient at providing primary palliative care and effective at determining when palliative care consultants are needed. In the acute setting, palliative care should be integrated with lifesaving treatments using a framework of determining goals of care, thoughtfully prognosticating, and engaging in shared decision-making. This framework remains important when aggressive treatments are not desired or not available, or when patients are admitted to the hospital for conditions related to advanced stages of chronic neurologic disease. Because prognostic uncertainty characterizes much of neurology, inpatient neurologists must develop communication strategies that account for uncertainty while supporting shared decision-making and allowing patients and families to preserve hope. In this article, we illustrate the approach to palliative care in inpatient neurology.
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Affiliation(s)
- Adeline L Goss
- Department of Neurology, University of California San Francisco, San Francisco, California
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Iltis AS, Mehta M, Sawinski D. Ignorance is Not Bliss: The Case for Comprehensive Reproductive Counseling for Women with Chronic Kidney Disease. HEC Forum 2021:10.1007/s10730-021-09463-7. [PMID: 34617168 DOI: 10.1007/s10730-021-09463-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/21/2021] [Indexed: 10/20/2022]
Abstract
The bioethics literature has paid little attention to matters of informed reproductive decision-making among women of childbearing age who have chronic kidney disease (CKD), including women who are on dialysis or women who have had a kidney transplant. Women with CKD receive inconsistent and, sometimes, inadequate reproductive counseling, particularly with respect to information about pursuing pregnancy. We identify four factors that might contribute to inadequate and inconsistent reproductive counseling. We argue that women with CKD should receive comprehensive reproductive counseling, including information about the possibility of pursuing pregnancy, and that more rigorous research on pregnancy in women with CKD, including women on dialysis or who have received a kidney transplant, is warranted to improve informed reproductive decision making in this population.
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Affiliation(s)
- Ana S Iltis
- Center for Bioethics, Health and Society, Wake Forest University, Winston-Salem, NC, USA.
| | - Maya Mehta
- Center for Bioethics, Health and Society, Wake Forest University, Winston-Salem, NC, USA
| | - Deirdre Sawinski
- Renal Electrolyte, and Hypertension Division, Department of Medicine, Hospital of the University of Pennsylvania, Philadelphia, PA, USA
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Affiliation(s)
- Matthew N Jaffa
- Neurocritical Care, Program in Trauma, Department of Neurology, University of Maryland School of Medicine, 22 South Greene St., Rm G7K18, Baltimore, MD, 21201, USA.
| | - Jamie E Podell
- Neurocritical Care, Program in Trauma, Department of Neurology, University of Maryland School of Medicine, 22 South Greene St., Rm G7K18, Baltimore, MD, 21201, USA
| | - Melissa Motta
- Neurocritical Care, Program in Trauma, Department of Neurology, University of Maryland School of Medicine, 22 South Greene St., Rm G7K18, Baltimore, MD, 21201, USA
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Gao L, Zhao CW, Hwang DY. End-of-Life Care Decision-Making in Stroke. Front Neurol 2021; 12:702833. [PMID: 34650502 PMCID: PMC8505717 DOI: 10.3389/fneur.2021.702833] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2021] [Accepted: 08/31/2021] [Indexed: 12/21/2022] Open
Abstract
Stroke is one of the leading causes of death and long-term disability in the United States. Though advances in interventions have improved patient survival after stroke, prognostication of long-term functional outcomes remains challenging, thereby complicating discussions of treatment goals. Stroke patients who require intensive care unit care often do not have the capacity themselves to participate in decision making processes, a fact that further complicates potential end-of-life care discussions after the immediate post-stroke period. Establishing clear, consistent communication with surrogates through shared decision-making represents best practice, as these surrogates face decisions regarding artificial nutrition, tracheostomy, code status changes, and withdrawal or withholding of life-sustaining therapies. Throughout decision-making, clinicians must be aware of a myriad of factors affecting both provider recommendations and surrogate concerns, such as cognitive biases. While decision aids have the potential to better frame these conversations within intensive care units, aids specific to goals-of-care decisions for stroke patients are currently lacking. This mini review highlights the difficulties in decision-making for critically ill ischemic stroke and intracerebral hemorrhage patients, beginning with limitations in current validated clinical scales and clinician subjectivity in prognostication. We outline processes for identifying patient preferences when possible and make recommendations for collaborating closely with surrogate decision-makers on end-of-life care decisions.
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Affiliation(s)
- Lucy Gao
- Yale School of Medicine, New Haven, CT, United States
| | | | - David Y. Hwang
- Division of Neurocritical Care and Emergency Neurology, Yale School of Medicine, New Haven, CT, United States
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Wijdicks EFM, Hwang DY. Predicting Coma Trajectories: The Impact of Bias and Noise on Shared Decisions. Neurocrit Care 2021; 35:291-296. [PMID: 34426900 PMCID: PMC8382106 DOI: 10.1007/s12028-021-01324-y] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2021] [Accepted: 07/28/2021] [Indexed: 11/30/2022]
Abstract
Coma trajectories are characterized by quick awakening or protracted awakening. Outcome is bookended by restored functionality or permanent cognitively and physically debilitated states. Given the stakes, prognostication cannot be easily questioned as a judgment call, and a scientific underpinning is elemental. Conventional wisdom in determining coma-outcome trajectories posits that (1) predictive models are better than personal experiences, (2) self-fulfilling prophesy is unchecked and driven by nihilism, with little regard for prior probability outcomes, and (3) recovery is impacted by patients’ prior wishes and preexisting medical conditions—but also by what families are told about the patient’s state and anticipated clinical course. Moreover, a predicted good outcome can be offset by a major subsequent complication, or a predicted poor outcome can be offset by aggressive care. This article examines some of these concepts, including how we decide on aggressiveness of care, how we judge quality of life, and the impact on outcome. Most patients who awaken quickly do well and can resume their pretrauma injury lives. In worse off, slow-to-awaken patients, outcomes are a mixed bag of limited innate resilience, depleted cognitive and physical reserves, and adjusted quality of life. Bias and noise are factors not easily measured in outcome prediction, but their influence on recovery trajectories raises some troubling issues.
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Affiliation(s)
- Eelco F M Wijdicks
- Neuroscience Intensive Care Units, Saint Marys Hospital, Mayo Clinic Campus, Rochester, MN, USA. .,Yale New Haven Hospital, New Haven, CT, USA. .,Division of Neurocritical Care and Hospital Neurology, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA.
| | - David Y Hwang
- Neuroscience Intensive Care Units, Saint Marys Hospital, Mayo Clinic Campus, Rochester, MN, USA.,Yale New Haven Hospital, New Haven, CT, USA
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Mc Lernon S, Werring D, Terry L. Clinicians' Perceptions of the Appropriateness of Neurocritical Care for Patients with Spontaneous Intracerebral Hemorrhage (ICH): A Qualitative Study. Neurocrit Care 2021; 35:162-171. [PMID: 33263147 PMCID: PMC7707900 DOI: 10.1007/s12028-020-01145-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2020] [Accepted: 10/30/2020] [Indexed: 11/02/2022]
Abstract
BACKGROUND AND OBJECTIVE Clinicians working in intensive care frequently report perceptions of inappropriate care (PIC) situations. Intracerebral haemorrhage (ICH) is associated with high rates of mortality and morbidity. Prognosticating after ICH is complex and may be influenced by clinicians' subjective impressions and biases, which may, in turn, influence decision making regarding the level of care provided. The aim of this study was to qualitatively explore perceptions of neurocritical care in relation to the expected functional outcome for ICH patients. DESIGN Qualitative study using semi-structured interviews with neurocritical care doctors and nurses. SETTING Neurocritical care (NCC) department in a UK neuroscience tertiary referral center. SUBJECTS Eleven neurocritical care nurses, five consultant neurointensivists, two stroke physicians, three neurosurgeons. INTERVENTION None. MEASUREMENTS AND MAIN RESULTS We conducted 21 semi-structured interviews and identified five key themes: (1) prognostic uncertainty (2) subjectivity of good versus poor outcome (3) perceived inappropriate care (PIC) situations (including for frail elderly patients) (4) challenging nature of decision-making (5) clinician distress. CONCLUSIONS Caring for severely affected ICH patients in need of neurocritical care is challenging, particularly with frail elderly patients. Awareness of the challenges could facilitate interventions to improve decision-making for this group of stroke patients and their families, as well as measures to reduce the distress on clinicians who care for this patient group. Our findings highlight the need for effective interdisciplinary shared decision making involving the family, taking into account patients' previously expressed values and preferences and incorporating these into bespoke care planning.
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Affiliation(s)
- Siobhan Mc Lernon
- School of Health and Social Care, London South Bank University, 103 Borough Road, London, SE1 OAA UK
| | - David Werring
- Stroke Research Centre, UCL Institute of Neurology, First Floor, Russell Square House, 10-12 Russell Square, London, WC1B 5EH UK
| | - Louise Terry
- School of Health and Social Care, London South Bank University, 103 Borough Road, London, SE1 OAA UK
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Joundi RA, Smith EE, Yu AYX, Rashid M, Fang J, Kapral MK. Temporal Trends in Case Fatality, Discharge Destination, and Admission to Long-term Care After Acute Stroke. Neurology 2021; 96:e2037-e2047. [PMID: 33970881 DOI: 10.1212/wnl.0000000000011791] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2020] [Accepted: 01/13/2021] [Indexed: 11/15/2022] Open
Abstract
OBJECTIVE To determine contemporary trends in case fatality, discharge destination, and admission to long-term care after acute ischemic stroke and intracerebral hemorrhage (ICH) using a large, population-based cohort. METHODS We used linked administrative data to identify all emergency department visits and hospital admissions for first-ever ischemic stroke or ICH in Ontario, Canada, from 2003 to 2017. We calculated crude and age-/sex-standardized risk of death at 30 days and 1 year from stroke onset. We stratified crude trends by stroke type, age, and sex and used the Kendall τ-b correlation coefficient to evaluate the significance of trends. We determined trends in discharge home and to rehabilitation and admission to long-term care at 1 year. We used Cox proportional hazard and logistic regression models to assess whether trends in outcomes persisted after adjustment for baseline factors, estimated stroke severity, and use of life-sustaining care. RESULTS There were 163,574 people with acute ischemic stroke or ICH across the study period. Between 2003 and 2017, age-/sex-standardized 30-day stroke case fatality decreased from 20.5% to 13.2% (7.3% absolute and 36% relative reduction) while that at 1 year decreased from 32.2% to 22.8% (9.3% absolute and 29% relative reduction). Findings were consistent across age, sex, and stroke type, and after adjustment for comorbid conditions, stroke severity, and use of life-sustaining care. There was a reduction in long-term care admission after ischemic stroke and an increase in discharge home or to rehabilitation for both stroke types. CONCLUSION We observed substantial reductions in acute stroke case fatality from 2003 to 2017 with a concurrent increase in discharge to home or rehabilitation and a decrease in long-term care admissions, suggesting continuous improvements in stroke systems of care.
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Affiliation(s)
- Raed A Joundi
- From the Department of Clinical Neurosciences (R.A.J., E.E.S.), Cumming School of Medicine, University of Calgary; ICES (R.A.J., A.Y.X.Y., M.R., J.F., M.K.K.), Toronto; and the Department of Medicine, Divisions of Neurology (A.Y.X.Y.) and General Internal Medicine (M.K.K.), and Institute of Health Policy, Management, and Evaluation (M.K.K.), University of Toronto, Canada
| | - Eric E Smith
- From the Department of Clinical Neurosciences (R.A.J., E.E.S.), Cumming School of Medicine, University of Calgary; ICES (R.A.J., A.Y.X.Y., M.R., J.F., M.K.K.), Toronto; and the Department of Medicine, Divisions of Neurology (A.Y.X.Y.) and General Internal Medicine (M.K.K.), and Institute of Health Policy, Management, and Evaluation (M.K.K.), University of Toronto, Canada
| | - Amy Y X Yu
- From the Department of Clinical Neurosciences (R.A.J., E.E.S.), Cumming School of Medicine, University of Calgary; ICES (R.A.J., A.Y.X.Y., M.R., J.F., M.K.K.), Toronto; and the Department of Medicine, Divisions of Neurology (A.Y.X.Y.) and General Internal Medicine (M.K.K.), and Institute of Health Policy, Management, and Evaluation (M.K.K.), University of Toronto, Canada
| | - Mohammed Rashid
- From the Department of Clinical Neurosciences (R.A.J., E.E.S.), Cumming School of Medicine, University of Calgary; ICES (R.A.J., A.Y.X.Y., M.R., J.F., M.K.K.), Toronto; and the Department of Medicine, Divisions of Neurology (A.Y.X.Y.) and General Internal Medicine (M.K.K.), and Institute of Health Policy, Management, and Evaluation (M.K.K.), University of Toronto, Canada
| | - Jiming Fang
- From the Department of Clinical Neurosciences (R.A.J., E.E.S.), Cumming School of Medicine, University of Calgary; ICES (R.A.J., A.Y.X.Y., M.R., J.F., M.K.K.), Toronto; and the Department of Medicine, Divisions of Neurology (A.Y.X.Y.) and General Internal Medicine (M.K.K.), and Institute of Health Policy, Management, and Evaluation (M.K.K.), University of Toronto, Canada
| | - Moira K Kapral
- From the Department of Clinical Neurosciences (R.A.J., E.E.S.), Cumming School of Medicine, University of Calgary; ICES (R.A.J., A.Y.X.Y., M.R., J.F., M.K.K.), Toronto; and the Department of Medicine, Divisions of Neurology (A.Y.X.Y.) and General Internal Medicine (M.K.K.), and Institute of Health Policy, Management, and Evaluation (M.K.K.), University of Toronto, Canada.
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Adapting to a New Normal After Severe Acute Brain Injury: An Observational Cohort Using a Sequential Explanatory Design. Crit Care Med 2021; 49:1322-1332. [PMID: 33730742 PMCID: PMC8282680 DOI: 10.1097/ccm.0000000000004947] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVES Treatment decisions following severe acute brain injury need to consider patients' goals-of-care and long-term outcomes. Using family members as respondents, we aimed to assess patients' goals-of-care in the ICU and explore the impact of adaptation on survivors who did not reach the level of recovery initially considered acceptable. DESIGN Prospective, observational, mixed-methods cohort study. SETTING Comprehensive stroke and level 1 trauma center in Pacific Northwest United States. PARTICIPANTS Family members of patients with severe acute brain injury in an ICU for greater than 2 days and Glasgow Coma Scale score less than 12. MEASUREMENTS AND MAIN RESULTS At enrollment, we asked what level of physical and cognitive recovery the patient would find acceptable. At 6 months, we assessed level of recovery through family surveys and chart review. Families of patients whose outcome was below that considered acceptable were invited for semistructured interviews, examined with content analysis. RESULTS For 184 patients, most family members set patients' minimally acceptable cognitive recovery at "able to think and communicate" or better (82%) and physical recovery at independence or better (66%). Among 170 patients with known 6-month outcome, 40% had died in hospital. Of 102 survivors, 33% were able to think and communicate, 13% were independent, and 10% died after discharge. Among survivors whose family member had set minimally acceptable cognitive function at "able to think and communicate," 64% survived below that level; for those with minimally acceptable physical function at independence, 80% survived below that. Qualitative analysis revealed two key themes: families struggled to adapt to a new, yet uncertain, normal and asked for support and guidance with ongoing treatment decisions. CONCLUSIONS AND RELEVANCE Six months after severe acute brain injury, most patients survived to a state their families initially thought would not be acceptable. Survivors and their families need more support and guidance as they adapt to a new normal and struggle with persistent uncertainty.
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Adapting a Traumatic Brain Injury Goals-of-Care Decision Aid for Critically Ill Patients to Intracerebral Hemorrhage and Hemispheric Acute Ischemic Stroke. Crit Care Explor 2021; 3:e0357. [PMID: 33786434 PMCID: PMC7994105 DOI: 10.1097/cce.0000000000000357] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023] Open
Abstract
Supplemental Digital Content is available in the text. Objectives: Families in the neurologic ICU urgently request goals-of-care decision support and shared decision-making tools. We recently developed a goals-of-care decision aid for surrogates of critically ill traumatic brain injury patients using a systematic development process adherent to the International Patient Decision Aid Standards. To widen its applicability, we adapted this decision aid to critically ill patients with intracerebral hemorrhage and large hemispheric acute ischemic stroke. Design: Prospective observational study. Setting: Two academic neurologic ICUs. Subjects: Twenty family members of patients in the neurologic ICU were recruited from July 2018 to October 2018. Interventions: None. Measurements and Main Results: We reviewed the existing critically ill traumatic brain injury patients decision aid for content and changed: 1) the essential background information, 2) disease-specific terminology to “hemorrhagic stroke” and “ischemic stroke”, and 3) disease-specific prognosis tailored to individual patients. We conducted acceptability and usability testing using validated scales. All three decision aids contain information from validated, disease-specific outcome prediction models, as recommended by international decision aid standards, including careful emphasis on their uncertainty. We replaced the individualizable icon arrays graphically depicting probabilities of a traumatic brain injury patient’s prognosis with icon arrays visualizing intracerebral hemorrhage and hemispheric acute ischemic stroke prognostic probabilities using high-quality disease-specific data. We selected the Intracerebral Hemorrhage Score with validated 12-month outcomes, and for hemispheric acute ischemic stroke, the 12-month outcomes from landmark hemicraniectomy trials. Twenty family members participated in acceptability and usability testing (n = 11 for the intracerebral hemorrhage decision aid; n = 9 for the acute ischemic stroke decision aid). Median usage time was 22 minutes (interquartile range, 16–26 min). Usability was excellent (median System Usability Scale = 84/100 [interquartile range, 61–93; with > 68 indicating good usability]); 89% of participants graded the decision aid content as good or excellent, and greater than or equal to 90% rated it favorably for information amount, balance, and comprehensibility. Conclusions: We successfully adapted goals-of-care decision aids for use in surrogates of critically ill patients with intracerebral hemorrhage and hemispheric acute ischemic stroke and found excellent usability and acceptability. A feasibility trial using these decision aids is currently ongoing to further validate their acceptability and test their feasibility for use in busy neurologic ICUs.
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Oh SN, Kim YA, Kim YJ, Shim HJ, Song EK, Kang JH, Kwon JH, Lee JL, Lee SN, Maeng CH, Kang EJ, Do YR, Yun HJ, Jung KH, Yun YH. The Attitudes of Physicians and the General Public toward Prognostic Disclosure of Different Serious Illnesses: a Korean Nationwide Study. J Korean Med Sci 2020; 35:e401. [PMID: 33289368 PMCID: PMC7721562 DOI: 10.3346/jkms.2020.35.e401] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/15/2020] [Accepted: 09/14/2020] [Indexed: 11/20/2022] Open
Abstract
BACKGROUND Although international guidelines recommend palliative care approaches for many serious illnesses, the palliative needs of patients with serious illnesses other than cancer are often unmet, mainly due to insufficient prognosis-related discussion. We investigated physicians' and the general public's respective attitudes toward prognostic disclosure for several serious illnesses. METHODS We conducted a cross-sectional survey of 928 physicians, sourced from 12 hospitals and the Korean Medical Association, and 1,005 members of the general public, sourced from all 17 administrative divisions in Korea. RESULTS For most illnesses, most physicians (adjusted proportions - end-organ failure, 99.0%; incurable genetic or neurologic disease, 98.5%; acquired immune deficiency syndrome [AIDS], 98.4%; stroke or Parkinson's disease, 96.0%; and dementia, 89.6%) and members of the general public (end-organ failure, 92.0%; incurable genetic or neurologic disease, 92.5%; AIDS, 91.5%; stroke or Parkinson's disease, 92.1%; and dementia, 86.9%) wanted to be informed if they had a terminal prognosis. For physicians and the general public, the primary factor to consider when disclosing terminal status was "the patient's right to know his/her condition" (31.0%). Yet, the general public was less likely to prefer prognostic disclosure than physicians. Particularly, when their family members were patients, more than 10% of the general public did not want patients to be informed of their terminal prognosis. For the general public, the main reason for not disclosing prognosis was "psychological burden such as anxiety and depression" (35.8%), while for the physicians it was "disclosure would have no beneficial effect" (42.4%). CONCLUSION Most Physicians and the general public agreed that disclosure of a terminal prognosis respects patient autonomy for several serious illnesses. The low response rate of physicians might limit the generalizability of the results.
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Affiliation(s)
- Si Nae Oh
- Department of Family Medicine, Seoul National University Hospital, Seoul, Korea
- Department of Medicine, Yonsei University Graduate School, Seoul, Korea
| | - Young Ae Kim
- Hospice & Palliative Care Branch, National Cancer Control Institute, National Cancer Center, Goyang, Korea
| | - Yu Jung Kim
- Department of Internal Medicine, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam, Korea
| | - Hyun Jeong Shim
- Division of Hematology and Medical Oncology, Department of Internal Medicine, Chonnam National University School of Medicine, Hwasun, Korea
| | - Eun Kee Song
- Division of Hematology/Oncology, Jeonbuk National University Medical School, Jeonju, Korea
| | - Jung Hun Kang
- Department of Internal Medicine, College of Medicine, Gyeongsang National University, Jinju, Korea
| | - Jung Hye Kwon
- Department of Internal Medicine, Kangdong Sacred Heart Hospital, Hallym University College of Medicine, Seoul, Korea
| | - Jung Lim Lee
- Department of Hemato-oncology, Daegu Fatima Hospital, Daegu, Korea
| | - Soon Nam Lee
- Department of Internal Medicine, Ewha Womans University School of Medicine, Seoul, Korea
| | - Chi Hoon Maeng
- Division of Medical Oncology and Hematology, Department of Internal Medicine, Kyung Hee University Hospital, College of Medicine, Kyung Hee University, Seoul, Korea
| | - Eun Joo Kang
- Division of Medical Oncology, Department of Internal Medicine, Korea University College of Medicine, Korea University Guro Hospital, Seoul, Korea
| | - Young Rok Do
- Department of Internal Medicine, Dongsan Medical Center, Keimyung University School of Medicine, Daegu, Korea
| | - Hwan Jung Yun
- Department of Internal Medicine, Chungnam National University Hospital, Daejeon, Korea
| | - Kyung Hae Jung
- Department of Oncology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Young Ho Yun
- Department of Family Medicine, Seoul National University Hospital, Seoul, Korea
- Department of Biomedical Science, Seoul National University College of Medicine, Seoul, Korea
- Cancer Research Institute, Seoul National University College of Medicine, Seoul, Korea.
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Watt AD, Jenkins NL, McColl G, Collins S, Desmond PM. Ethical Issues in the Treatment of Late-Stage Alzheimer's Disease. J Alzheimers Dis 2020; 68:1311-1316. [PMID: 30475773 PMCID: PMC6484269 DOI: 10.3233/jad-180865] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
There is hope that the continuing efforts of researchers will yield a disease-modifying drug for Alzheimer’s disease. Such a drug is likely to be capable of halting, or significantly slowing, the underlying pathological processes driving cognitive decline; however, it is unlikely to be capable of restoring brain function already lost through the pathological process. A therapy capable of halting Alzheimer’s disease, while not providing restoration of function, may prompt serious ethical questions. For example, is there a stage in the disease process when it becomes too late for therapeutic intervention to commence? And who bears the responsibility of making such a decision? Conversations regarding the ethics of treating neurodegenerative conditions with non-restorative drugs have been largely absent within both clinical and research communities. Such discussions are urgently required to ensure that patients’ rights and well-being are protected when such therapeutic options become available.
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Affiliation(s)
- Andrew D Watt
- The Department of Pharmacology and Therapeutics, The University of Melbourne, Melbourne, VIC, Australia
| | - Nicole L Jenkins
- Melbourne Dementia Research Centre, The Florey Institute of Neuroscience and Mental Health, The University of Melbourne, Melbourne, VIC, Australia
| | - Gawain McColl
- Melbourne Dementia Research Centre, The Florey Institute of Neuroscience and Mental Health, The University of Melbourne, Melbourne, VIC, Australia
| | - Steven Collins
- Department of Medicine (RMH), The University of Melbourne, Melbourne, VIC, Australia
| | - Patricia M Desmond
- Department of Medicine and Radiology, Royal Melbourne Hospital, University of Melbourne, Melbourne, VIC, Australia
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Visvanathan A, Whiteley W, Mead G, Lawton J, Doubal FN, Dennis M. Reporting “specific abilities” after major stroke to better describe prognosis. J Stroke Cerebrovasc Dis 2020; 29:104993. [DOI: 10.1016/j.jstrokecerebrovasdis.2020.104993] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2020] [Revised: 05/21/2020] [Accepted: 05/22/2020] [Indexed: 12/23/2022] Open
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Everett EA, Everett W, Brier MR, White P. Appraisal of Health States Worse Than Death in Patients With Acute Stroke. Neurol Clin Pract 2020; 11:43-48. [PMID: 33968471 DOI: 10.1212/cpj.0000000000000856] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2019] [Accepted: 02/21/2020] [Indexed: 12/14/2022]
Abstract
Objective To identify health states that patients with acute stroke deem worse than death and to explore potential predictors for these ratings. Methods This was a cross-sectional study involving patients admitted to an urban comprehensive stroke center with acute stroke. Participants were asked to rate 10 possible health states/functional outcomes as better or worse than death using a 5-point Likert scale. Principal component analysis (PCA) was used to reduce clusters of correlated ratings to summary components (factors). These components were then analyzed using linear regression to identify possible predictive variables. Results Eighty patients participated. The states deemed equal to or worse than death by the majority of participants were relying on a breathing machine (66%) or feeding tube (66%), persistent confusion (62%), inability to communicate with others (58%), and bowel/bladder incontinence (50%). PCA revealed 2 factors of correlated variables: factor 1 composed primarily of relying on a feeding tube or breathing machine, incontinence, chronic pain, and persistent confusion, and factor 2 composed primarily of using a wheelchair, being bedbound, living in a nursing home, and requiring help for activities of daily living. The only significant predictor found was race for factor 1, with black participants finding these states more preferable to death than white participants. Discussion A substantial number of patients found multiple common outcomes of stroke to be the same as or worse than death. This highlights the importance of realistic discussions about expected functional outcomes with patients and/or their surrogate decision makers when considering goals of care after stroke.
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Affiliation(s)
- Elyse A Everett
- Department of Medicine (EAE, PW) and Department of Neurology (WE, MRB), Washington University in St. Louis, MO
| | - William Everett
- Department of Medicine (EAE, PW) and Department of Neurology (WE, MRB), Washington University in St. Louis, MO
| | - Matthew R Brier
- Department of Medicine (EAE, PW) and Department of Neurology (WE, MRB), Washington University in St. Louis, MO
| | - Patrick White
- Department of Medicine (EAE, PW) and Department of Neurology (WE, MRB), Washington University in St. Louis, MO
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Abstract
Stroke is a sudden, unexpected illness with an uncertain prognosis for functional recovery. Ethical issues in the care of patients with stroke include assessment of decision-making capacity when cognition or communication is impaired, prognostication, evaluation of quality of life, withdrawal or withholding of life-sustaining treatment, and how to optimize surrogate decision making. Skilled communication between clinicians and patients or their surrogates promotes shared decision making and may prevent ethical conflict. Nurses with an understanding of the ethics of stroke care play an important role in the care of patients with stroke and their families.
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Abstract
Consider the hypothetical case of a 75-year-old patient admitted to the intensive care unit (ICU) for acute hypoxic respiratory failure due to pneumonia and systolic heart failure. Although she suffers from a potentially treatable infection, her advanced age and chronic illness increase her risk of experiencing a poor outcome. Her family feels conflicted about whether the use of mechanical ventilation would be acceptable given what they understand about her values and preferences. In the ICU setting, clinicians, patients, and surrogate decision-makers frequently face challenges of prognostic uncertainty as well as uncertainty regarding patients' goals and values. Time-limited trials (TLTs) of life-sustaining treatments in the ICU have been proposed as one strategy to help facilitate goal-concordant care in the midst of a complex and high-stakes decision-making environment. TLTs represent an agreement between clinicians and patients or surrogate decision-makers to employ a therapy for an agreed-upon time period, with a plan for subsequent reassessment of the patient's progress according to previously-established criteria for improvement or decline. Herein, we review the concept of TLTs in intensive care, and explore their potential benefits, barriers, and challenges. Research demonstrates that, in practice, TLTs are conducted infrequently and often incompletely, and are challenged by system-level factors that diminish their effectiveness. The promise of TLTs in intensive care warrants continued research efforts, including implementation studies to improve adoption and fidelity, observational research to determine optimal timeframes for TLTs, and interventional trials to determine if TLTs ultimately improve the delivery of goal-concordant care in the ICU.
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Fahlström A, Tobieson L, Redebrandt HN, Zeberg H, Bartek J, Bartley A, Erkki M, Hessington A, Troberg E, Mirza S, Tsitsopoulos PP, Marklund N. Differences in neurosurgical treatment of intracerebral haemorrhage: a nation-wide observational study of 578 consecutive patients. Acta Neurochir (Wien) 2019; 161:955-965. [PMID: 30877470 PMCID: PMC6484090 DOI: 10.1007/s00701-019-03853-0] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2018] [Accepted: 02/13/2019] [Indexed: 01/08/2023]
Abstract
BACKGROUND Supratentorial intracerebral haemorrhage (ICH) carries an excessive mortality and morbidity. Although surgical ICH treatment can be life-saving, the indications for surgery in larger cohorts of ICH patients are controversial and not well defined. We hypothesised that surgical indications vary substantially among neurosurgical centres in Sweden. OBJECTIVE In this nation-wide retrospective observational study, differences in treatment strategies among all neurosurgical departments in Sweden were evaluated. METHODS Patient records, neuroimaging and clinical outcome focused on 30-day mortality were collected on each operated ICH patient treated at any of the six neurosurgical centres in Sweden from 1 January 2011 to 31 December 2015. RESULTS In total, 578 consecutive surgically treated ICH patients were evaluated. There was a similar incidence of surgical treatment among different neurosurgical catchment areas. Patient selection for surgery was similar among the centres in terms of patient age, pre-operative level of consciousness and co-morbidities, but differed in ICH volume, proportion of deep-seated vs. lobar ICH and pre-operative signs of herniation (p < .05). Post-operative patient management strategies, including the use of ICP-monitoring, CSF-drainage and mechanical ventilation, varied among centres (p < .05). The 30-day mortality ranged between 10 and 28%. CONCLUSIONS Although indications for surgical treatment of ICH in the six Swedish neurosurgical centres were homogenous with regard to age and pre-operative level of consciousness, important differences in ICH volume, proportion of deep-seated haemorrhages and pre-operative signs of herniation were observed, and there was a substantial variability in post-operative management. The present results reflect the need for refined evidence-based guidelines for surgical management of ICH.
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Affiliation(s)
- Andreas Fahlström
- Department of Neuroscience, Neurosurgery, Uppsala University, Uppsala University Hospital, SE-751 85, Uppsala, Sweden.
| | - Lovisa Tobieson
- Department of Neurosurgery and Department of Clinical and Experimental Medicine, Linköping University, Linköping, Sweden
| | - Henrietta Nittby Redebrandt
- Department of Clinical Sciences Lund, Neurosurgery, Lund University, Skane University Hospital, Lund, Sweden
| | - Hugo Zeberg
- Department of Neuroscience, Karolinska Institutet, Stockholm, Sweden
| | - Jiri Bartek
- Department of Medicine and Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
- Department of Neurosurgery, Karolinska University Hospital, Stockholm, Sweden
- Department of Neurosurgery, Copenhagen University Hospital Rigshospitalet, Copenhagen, Denmark
| | - Andreas Bartley
- Department of Clinical Neuroscience, Neurosurgery, University of Gothenburg, Sahlgrenska Academy, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Maria Erkki
- Department of Clinical Neuroscience, Neurosurgery, Umeå University, Umeå University Hospital, Umeå, Sweden
| | - Amel Hessington
- Department of Neuroscience, Neurosurgery, Uppsala University, Uppsala University Hospital, SE-751 85, Uppsala, Sweden
| | - Ebba Troberg
- Department of Clinical Sciences Lund, Neurosurgery, Lund University, Skane University Hospital, Lund, Sweden
| | - Sadia Mirza
- Department of Medicine and Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
| | - Parmenion P Tsitsopoulos
- Department of Neuroscience, Neurosurgery, Uppsala University, Uppsala University Hospital, SE-751 85, Uppsala, Sweden
| | - Niklas Marklund
- Department of Neuroscience, Neurosurgery, Uppsala University, Uppsala University Hospital, SE-751 85, Uppsala, Sweden
- Department of Neurosurgery and Department of Clinical and Experimental Medicine, Linköping University, Linköping, Sweden
- Department of Clinical Sciences Lund, Neurosurgery, Lund University, Skane University Hospital, Lund, Sweden
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Steigleder T, Kollmar R, Ostgathe C. Palliative Care for Stroke Patients and Their Families: Barriers for Implementation. Front Neurol 2019; 10:164. [PMID: 30894836 PMCID: PMC6414790 DOI: 10.3389/fneur.2019.00164] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2018] [Accepted: 02/07/2019] [Indexed: 11/17/2022] Open
Abstract
Stroke is a leading cause of death, disability and is a symptom burden worldwide. It impacts patients and their families in various ways, including physical, emotional, social, and spiritual aspects. As stroke is potentially lethal and causes severe symptom burden, a palliative care (PC) approach is indicated in accordance with the definition of PC published by the WHO in 2002. Stroke patients can benefit from a structured approach to palliative care needs (PCN) and the amelioration of symptom burden. Stroke outcome is uncertain and outlook may change rapidly. Regarding these challenges, core competencies of PC include the critical appraisal of various treatment options, and openly and respectfully discussing therapeutic goals with patients, families, and caregivers. Nevertheless, PC in stroke has to date mainly been restricted to short care periods for dying patients after life-limiting complications. There is currently no integrated concept for PC in stroke care addressing the appropriate moment to initiate PC for stroke patients, and the question of how to screen for symptoms remains unanswered. Therefore, PC for stroke patients is often perceived as a stopgap in cases of unfavorable prognosis and very short survival times. In contrast, PC can provide much more for stroke patients and support a holistic approach, improve quality of life and ensure treatment according to the patient's wishes and values. In this short review we identify key aspects of PC in stroke care and current barriers to implementation. Additionally, we provide insights into our approach to PC in stroke care.
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Affiliation(s)
- Tobias Steigleder
- Department of Palliative Care, University Hospital Erlangen-Nuremberg, Erlangen, Germany
- Department of Neurology, University Hospital Erlangen-Nuremberg, Erlangen, Germany
| | - Rainer Kollmar
- Department of Neurology and Neurointensive Care, Darmstadt Academic Hospital, Darmstadt, Germany
| | - Christoph Ostgathe
- Department of Palliative Care, University Hospital Erlangen-Nuremberg, Erlangen, Germany
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Withdrawal of Life-Sustaining Treatments in Perceived Devastating Brain Injury: The Key Role of Uncertainty. Neurocrit Care 2019; 30:33-41. [PMID: 30143963 DOI: 10.1007/s12028-018-0595-8] [Citation(s) in RCA: 43] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
BACKGROUND Withdrawal of life-sustaining treatment (WOLST) is the leading proximate cause of death in patients with perceived devastating brain injury (PDBI). There are reasons to believe that a potentially significant proportion of WOLST decisions, in this setting, are premature and guided by a number of assumptions that falsely confer a sense of certainty. METHOD This manuscript proposes that these assumptions face serious challenges, and that we should replace unwarranted certainty with an appreciation for the great degree of multi-dimensional uncertainty involved. The article proceeds by offering a taxonomy of uncertainty in PDBI and explores the key role that uncertainty as a cognitive state, may play into how WOLST decisions are reached. CONCLUSION In order to properly share decision-making with families and surrogates of patients with PDBI, we will have to acknowledge, understand, and be able to communicate the great degree of uncertainty involved.
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Creutzfeldt CJ, Kluger B, Kelly AG, Lemmon M, Hwang DY, Galifianakis NB, Carver A, Katz M, Curtis JR, Holloway RG. Neuropalliative care: Priorities to move the field forward. Neurology 2018; 91:217-226. [PMID: 29950434 DOI: 10.1212/wnl.0000000000005916] [Citation(s) in RCA: 82] [Impact Index Per Article: 13.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2018] [Accepted: 04/06/2018] [Indexed: 11/15/2022] Open
Abstract
Neuropalliative care is an emerging subspecialty in neurology and palliative care. On April 26, 2017, we convened a Neuropalliative Care Summit with national and international experts in the field to develop a clinical, educational, and research agenda to move the field forward. Clinical priorities included the need to develop and implement effective models to integrate palliative care into neurology and to develop and implement informative quality measures to evaluate and compare palliative approaches. Educational priorities included the need to improve the messaging of palliative care and to create standards for palliative care education for neurologists and neurology education for palliative specialists. Research priorities included the need to improve the evidence base across the entire research spectrum from early-stage interventional research to implementation science. Highest priority areas include focusing on outcomes important to patients and families, developing serious conversation triggers, and developing novel approaches to patient and family engagement, including improvements to decision quality. As we continue to make remarkable advances in the prevention, diagnosis, and treatment of neurologic illness, neurologists will face an increasing need to guide and support patients and families through complex choices involving immense uncertainty and intensely important outcomes of mind and body. This article outlines opportunities to improve the quality of care for all patients with neurologic illness and their families through a broad range of clinical, educational, and investigative efforts that include complex symptom management, communication skills, and models of care.
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Affiliation(s)
- Claire J Creutzfeldt
- From the Department of Neurology (C.J.C.), University of Washington, Harborview Medical Center, Seattle; Department of Neurology (B.K.), University of Colorado Anschutz Medical Center, Denver; Department of Neurology (A.G.K., R.G.H.), University of Rochester Medical Center, NY; Department of Pediatrics (M.L.), Division of Child Neurology, Duke University Hospital, Durham, NC; Division of Neurocritical Care and Emergency Neurology (D.Y.H.) and Center for Neuroepidemiology and Clinical Neurological Research (D.Y.H.), Yale School of Medicine, New Haven, CT; Department of Neurology (N.B.G., M.K.), University of California in San Francisco; Department of Neurology (A.C.), Memorial Sloan Kettering Cancer Center, New York, NY; and Cambia Palliative Care Center of Excellence (J.R.C.), University of Washington, Seattle.
| | - Benzi Kluger
- From the Department of Neurology (C.J.C.), University of Washington, Harborview Medical Center, Seattle; Department of Neurology (B.K.), University of Colorado Anschutz Medical Center, Denver; Department of Neurology (A.G.K., R.G.H.), University of Rochester Medical Center, NY; Department of Pediatrics (M.L.), Division of Child Neurology, Duke University Hospital, Durham, NC; Division of Neurocritical Care and Emergency Neurology (D.Y.H.) and Center for Neuroepidemiology and Clinical Neurological Research (D.Y.H.), Yale School of Medicine, New Haven, CT; Department of Neurology (N.B.G., M.K.), University of California in San Francisco; Department of Neurology (A.C.), Memorial Sloan Kettering Cancer Center, New York, NY; and Cambia Palliative Care Center of Excellence (J.R.C.), University of Washington, Seattle
| | - Adam G Kelly
- From the Department of Neurology (C.J.C.), University of Washington, Harborview Medical Center, Seattle; Department of Neurology (B.K.), University of Colorado Anschutz Medical Center, Denver; Department of Neurology (A.G.K., R.G.H.), University of Rochester Medical Center, NY; Department of Pediatrics (M.L.), Division of Child Neurology, Duke University Hospital, Durham, NC; Division of Neurocritical Care and Emergency Neurology (D.Y.H.) and Center for Neuroepidemiology and Clinical Neurological Research (D.Y.H.), Yale School of Medicine, New Haven, CT; Department of Neurology (N.B.G., M.K.), University of California in San Francisco; Department of Neurology (A.C.), Memorial Sloan Kettering Cancer Center, New York, NY; and Cambia Palliative Care Center of Excellence (J.R.C.), University of Washington, Seattle
| | - Monica Lemmon
- From the Department of Neurology (C.J.C.), University of Washington, Harborview Medical Center, Seattle; Department of Neurology (B.K.), University of Colorado Anschutz Medical Center, Denver; Department of Neurology (A.G.K., R.G.H.), University of Rochester Medical Center, NY; Department of Pediatrics (M.L.), Division of Child Neurology, Duke University Hospital, Durham, NC; Division of Neurocritical Care and Emergency Neurology (D.Y.H.) and Center for Neuroepidemiology and Clinical Neurological Research (D.Y.H.), Yale School of Medicine, New Haven, CT; Department of Neurology (N.B.G., M.K.), University of California in San Francisco; Department of Neurology (A.C.), Memorial Sloan Kettering Cancer Center, New York, NY; and Cambia Palliative Care Center of Excellence (J.R.C.), University of Washington, Seattle
| | - David Y Hwang
- From the Department of Neurology (C.J.C.), University of Washington, Harborview Medical Center, Seattle; Department of Neurology (B.K.), University of Colorado Anschutz Medical Center, Denver; Department of Neurology (A.G.K., R.G.H.), University of Rochester Medical Center, NY; Department of Pediatrics (M.L.), Division of Child Neurology, Duke University Hospital, Durham, NC; Division of Neurocritical Care and Emergency Neurology (D.Y.H.) and Center for Neuroepidemiology and Clinical Neurological Research (D.Y.H.), Yale School of Medicine, New Haven, CT; Department of Neurology (N.B.G., M.K.), University of California in San Francisco; Department of Neurology (A.C.), Memorial Sloan Kettering Cancer Center, New York, NY; and Cambia Palliative Care Center of Excellence (J.R.C.), University of Washington, Seattle
| | - Nicholas B Galifianakis
- From the Department of Neurology (C.J.C.), University of Washington, Harborview Medical Center, Seattle; Department of Neurology (B.K.), University of Colorado Anschutz Medical Center, Denver; Department of Neurology (A.G.K., R.G.H.), University of Rochester Medical Center, NY; Department of Pediatrics (M.L.), Division of Child Neurology, Duke University Hospital, Durham, NC; Division of Neurocritical Care and Emergency Neurology (D.Y.H.) and Center for Neuroepidemiology and Clinical Neurological Research (D.Y.H.), Yale School of Medicine, New Haven, CT; Department of Neurology (N.B.G., M.K.), University of California in San Francisco; Department of Neurology (A.C.), Memorial Sloan Kettering Cancer Center, New York, NY; and Cambia Palliative Care Center of Excellence (J.R.C.), University of Washington, Seattle
| | - Alan Carver
- From the Department of Neurology (C.J.C.), University of Washington, Harborview Medical Center, Seattle; Department of Neurology (B.K.), University of Colorado Anschutz Medical Center, Denver; Department of Neurology (A.G.K., R.G.H.), University of Rochester Medical Center, NY; Department of Pediatrics (M.L.), Division of Child Neurology, Duke University Hospital, Durham, NC; Division of Neurocritical Care and Emergency Neurology (D.Y.H.) and Center for Neuroepidemiology and Clinical Neurological Research (D.Y.H.), Yale School of Medicine, New Haven, CT; Department of Neurology (N.B.G., M.K.), University of California in San Francisco; Department of Neurology (A.C.), Memorial Sloan Kettering Cancer Center, New York, NY; and Cambia Palliative Care Center of Excellence (J.R.C.), University of Washington, Seattle
| | - Maya Katz
- From the Department of Neurology (C.J.C.), University of Washington, Harborview Medical Center, Seattle; Department of Neurology (B.K.), University of Colorado Anschutz Medical Center, Denver; Department of Neurology (A.G.K., R.G.H.), University of Rochester Medical Center, NY; Department of Pediatrics (M.L.), Division of Child Neurology, Duke University Hospital, Durham, NC; Division of Neurocritical Care and Emergency Neurology (D.Y.H.) and Center for Neuroepidemiology and Clinical Neurological Research (D.Y.H.), Yale School of Medicine, New Haven, CT; Department of Neurology (N.B.G., M.K.), University of California in San Francisco; Department of Neurology (A.C.), Memorial Sloan Kettering Cancer Center, New York, NY; and Cambia Palliative Care Center of Excellence (J.R.C.), University of Washington, Seattle
| | - J Randall Curtis
- From the Department of Neurology (C.J.C.), University of Washington, Harborview Medical Center, Seattle; Department of Neurology (B.K.), University of Colorado Anschutz Medical Center, Denver; Department of Neurology (A.G.K., R.G.H.), University of Rochester Medical Center, NY; Department of Pediatrics (M.L.), Division of Child Neurology, Duke University Hospital, Durham, NC; Division of Neurocritical Care and Emergency Neurology (D.Y.H.) and Center for Neuroepidemiology and Clinical Neurological Research (D.Y.H.), Yale School of Medicine, New Haven, CT; Department of Neurology (N.B.G., M.K.), University of California in San Francisco; Department of Neurology (A.C.), Memorial Sloan Kettering Cancer Center, New York, NY; and Cambia Palliative Care Center of Excellence (J.R.C.), University of Washington, Seattle
| | - Robert G Holloway
- From the Department of Neurology (C.J.C.), University of Washington, Harborview Medical Center, Seattle; Department of Neurology (B.K.), University of Colorado Anschutz Medical Center, Denver; Department of Neurology (A.G.K., R.G.H.), University of Rochester Medical Center, NY; Department of Pediatrics (M.L.), Division of Child Neurology, Duke University Hospital, Durham, NC; Division of Neurocritical Care and Emergency Neurology (D.Y.H.) and Center for Neuroepidemiology and Clinical Neurological Research (D.Y.H.), Yale School of Medicine, New Haven, CT; Department of Neurology (N.B.G., M.K.), University of California in San Francisco; Department of Neurology (A.C.), Memorial Sloan Kettering Cancer Center, New York, NY; and Cambia Palliative Care Center of Excellence (J.R.C.), University of Washington, Seattle
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Hwang DY, George BP, Kelly AG, Schneider EB, Sheth KN, Holloway RG. Variability in Gastrostomy Tube Placement for Intracerebral Hemorrhage Patients at US Hospitals. J Stroke Cerebrovasc Dis 2017; 27:978-987. [PMID: 29221969 DOI: 10.1016/j.jstrokecerebrovasdis.2017.11.001] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2017] [Revised: 10/11/2017] [Accepted: 11/01/2017] [Indexed: 01/06/2023] Open
Abstract
OBJECTIVE We sought to characterize the variability among US hospitals with regard to gastrostomy tube placement for inpatients with intracerebral hemorrhage (ICH). METHODS Using the Nationwide Inpatient Sample, we examined variations in the annual rate of gastrostomy tube placement from 2002 to 2011 for ICH patients admitted to hospitals with 30 or more annual ICH admissions. We then directly compared, among these hospitals, their individual frequencies of gastrostomy tube placement for ICH patients over the same time period. To quantify variability among hospitals, we used multilevel multivariable regression models accounting for a hospital random effect, adjusted for patient-level and hospital-level factors predictors of placement. RESULTS Gastrostomy tube placement rates did not significantly change from 2002 to 2011 (9.8 to 8.7 per 100 admissions; P trend = .57). Among 690 hospitals with 38,080 ICH hospitalizations during this period, 10.4% of patients had a gastrostomy tube placed (n = 3976). Variation in the rate of placement among individual hospitals was large, from 0% to 34.4% (interquartile range 5.7%-13.6%). For a regression model controlling for patient and hospital covariates, the median odds ratio was 1.36 (95% confidence interval 1.28-1.44), indicating that if a patient moved from one hospital to another with a higher intrinsic propensity of placement, there was a 1.36-fold median increase in the odds of receiving a gastrostomy tube, independent of patient and hospital factors. CONCLUSIONS Variation in gastrostomy tube placement rates across hospitals is large and may in part reflect differences in local practice patterns or patient and surrogate preferences.
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Affiliation(s)
- David Y Hwang
- Department of Neurology, Division of Neurocritical Care and Emergency Neurology, Yale School of Medicine, New Haven, Connecticut; Center for Neuroepidemiology and Clinical Neurological Research, Yale School of Medicine, Yale University, New Haven, Connecticut.
| | - Benjamin P George
- Department of Neurology, University of Rochester School of Medicine and Dentistry, Rochester, New York
| | - Adam G Kelly
- Department of Neurology, University of Rochester School of Medicine and Dentistry, Rochester, New York
| | - Eric B Schneider
- Center for Surgery and Public Health, Brigham and Women's Hospital, Boston, Massachusetts; Department of Surgery, Johns Hopkins School of Medicine, Baltimore, Maryland
| | - Kevin N Sheth
- Department of Neurology, Division of Neurocritical Care and Emergency Neurology, Yale School of Medicine, New Haven, Connecticut; Center for Neuroepidemiology and Clinical Neurological Research, Yale School of Medicine, Yale University, New Haven, Connecticut
| | - Robert G Holloway
- Department of Neurology, University of Rochester School of Medicine and Dentistry, Rochester, New York
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Neugebauer H, Schnabl M, Lulé D, Heuschmann PU, Jüttler E. Attitudes of Patients and Relatives Toward Disability and Treatment in Malignant MCA Infarction. Neurocrit Care 2017; 26:311-318. [PMID: 27966092 DOI: 10.1007/s12028-016-0362-7] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
BACKGROUND Attitudes among patients and relatives toward the degree of acceptable disability and the importance of aphasia are critical in deciding on decompressive hemicraniectomy (DHC) in malignant middle cerebral artery infarction (MMI). However, most MMI patients are not able to communicate their will. Furthermore, attitudes of healthy individuals and relatives may not correspond to those of stroke patients. METHODS This is a multicenter survey among 355 patients and 199 relatives during treatment for acute minor or moderate severe ischemic stroke in Germany. Questions address the acceptance of disability, importance of aphasia, and the preferred treatment in the hypothetical case of future MMI. RESULTS mRS scores of 2 or better were considered acceptable by the majority of all respondents (72.9-88.1%). A mRS of 3, 4, and 5 was considered acceptable by 56.0, 24.5, and 6.8%, respectively. Except for a mRS of 1, relatives indicated each grade of disability significantly more often acceptable than patients. Differences regarding acceptable disability and treatment decision were depending on family status, housing situation, need of care, and disability. The presence of aphasia was considered important for treatment decision by both patients (46.5%) and relatives (39.2%). Older respondents more often refrained from DHC (p < 0.001). CONCLUSION In Germany, there is substantial heterogeneity in patients and relatives regarding acceptable disability, aphasia, and treatment decision in the hypothetical case of MMI. Relatives significantly overestimate the degree of disability that is acceptable to stroke patients. Further studies are warranted to determine whether differences in attitudes impact on the decision to undergo DHC.
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Affiliation(s)
- Hermann Neugebauer
- Department of Neurology, University of Ulm, Ulm, Germany.
- RKU - University and Rehabilitation Hospitals Ulm, Oberer Eselsberg 45, 89081, Ulm, Germany.
| | - Matthias Schnabl
- Department of Trauma Surgery and Orthopedics, Community Hospital Kliniken Nordoberpfalz AG Klinikum Weiden, Weiden in der Oberpfalz, Germany
| | - Dorothée Lulé
- Department of Neurology, University of Ulm, Ulm, Germany
| | - Peter U Heuschmann
- Institute for Clinical Epidemiology and Biometry, University of Würzburg, Würzburg, Germany
- Comprehensive Heart Failure Center, University of Würzburg, Würzburg, Germany
| | - Eric Jüttler
- Department of Neurology, University of Ulm, Ulm, Germany
- Department of Neurology, Ostalb-Klinikum Aalen, Aalen, Germany
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Abstract
BACKGROUND Integration of palliative care (PC) into the neurological intensive care unit (neuro-ICU) is increasingly recommended, but evidence regarding the best practice is lacking. We conducted a qualitative analysis exploring current practices and key themes of specialist PC consultations in patients admitted to a single neuro-ICU. METHODS We retrospectively identified all patients who were admitted to the neuro-ICU for ≥24 h and received a PC consultation between January and August 2014. We reviewed PC consultation notes and neuro-ICU progress notes from the electronic health records of these patients. We performed content analysis on the PC notes. RESULTS Twenty-five neuro-ICU patients (4 %) received a PC consultation over 8 months with the most prevalent reason of clarifying goals of care. The main distinctions between patients with and those without (n = 580) a PC consultation were ICU length of stay (median 8.2 vs. 2.8 days) and death in the neuro-ICU (56 % vs. 11 %). The most prevalent themes addressed in the PC consultation notes were (1) discussing prognosis, (2) eliciting patient and family values, (3) understanding medical options, and (4) identifying conflict. CONCLUSIONS PC consultations in the neuro-ICU emphasize family coping and decision-making by helping discuss prognosis and exploring patient and family values as well as their ability to understand the medical information. Several features suggest that earlier integration of PC into neuro-ICU care may enhance both coping and the decision-making process.
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Visvanathan A, Dennis M, Mead G, Whiteley WN, Lawton J, Doubal FN. Shared decision making after severe stroke—How can we improve patient and family involvement in treatment decisions? Int J Stroke 2017; 12:920-922. [DOI: 10.1177/1747493017730746] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
People who are well may regard survival with disability as being worse than death. However, this is often not the case when those surviving with disability (e.g. stroke survivors) are asked the same question. Many routine treatments provided after an acute stroke (e.g. feeding via a tube) increase survival, but with disability. Therefore, clinicians need to support patients and families in making informed decisions about the use of these treatments, in a process termed shared decision making. This is challenging after acute stroke: there is prognostic uncertainty, patients are often too unwell to participate in decision making, and proxies may not know the patients’ expressed wishes (i.e. values). Patients’ values also change over time and in different situations. There is limited evidence on successful methods to facilitate this process. Changes targeted at components of shared decision making (e.g. decision aids to provide information and discussing patient values) increase patient satisfaction. How this influences decision making is unclear. Presumably, a “shared decision-making tool” that introduces effective changes at various stages in this process might be helpful after acute stroke. For example, by complementing professional judgement with predictions from prognostic models, clinicians could provide information that is more accurate. Decision aids that are personalized may be helpful. Further qualitative research can provide clinicians with a better understanding of patient values and factors influencing this at different time points after a stroke. The evaluation of this tool in its success to achieve outcomes consistent with patients’ values may require more than one clinical trial.
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Affiliation(s)
- Akila Visvanathan
- Centre for Clinical Brain Sciences, University of Edinburgh, Edinburgh, UK
| | - Martin Dennis
- Centre for Clinical Brain Sciences, University of Edinburgh, Edinburgh, UK
| | - Gillian Mead
- Centre for Clinical Brain Sciences, University of Edinburgh, Edinburgh, UK
| | - William N Whiteley
- Centre for Clinical Brain Sciences, University of Edinburgh, Edinburgh, UK
| | - Julia Lawton
- Usher Institute for Population Sciences, Edinburgh, UK
| | - Fergus Neil Doubal
- Centre for Clinical Brain Sciences, University of Edinburgh, Edinburgh, UK
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Management of Acute Stroke in the Older Person. Geriatrics (Basel) 2017; 2:geriatrics2030027. [PMID: 31011037 PMCID: PMC6371128 DOI: 10.3390/geriatrics2030027] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2017] [Revised: 07/21/2017] [Accepted: 07/31/2017] [Indexed: 12/27/2022] Open
Abstract
The majority of people who suffer a stroke are older adults. The last two decades have brought major progress in the diagnosis and management of stroke, which has led to significant reductions in mortality, long-term disability, and the need for institutional care. However, acute, interventional and preventative treatments have mostly been trialled in younger age groups. In this article we will provide an overview of the evidence for acute stroke treatments in relation to age, discuss special considerations in the older person, and contemplate patient choice, quality of life, and end-of-life-decisions.
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