Long-Term Psychological Distress Among Surrogate Decision Makers for Mexican American and Non-Hispanic White Patients With Severe Stroke

Palliative and End-of-Life Care in Stroke: A Scientific Statement From the American Heart Association

OBJECTIVE

To provide an update on palliative care needs specific to stroke and provide key points for clinicians and health care systems caring for patients with stroke and their families.

METHODS

Members of the writing group were chosen to represent the multidisciplinary team of professionals who care for people who have had a stroke. Each member was assigned a topic within their area of expertise, reviewed the literature, and drafted content with a focus on the past decade to complement the 2014 American Heart Association scientific statement on palliative and end-of-life care in stroke.

RESULTS

Stroke has multidimensional effects on patients and their families because of threats to personhood, prognostic uncertainty, and the need to adapt to functional changes after stroke. Palliative care has evolved as both a specialty and a skillset with a goal to improve communication about goals of care and quality of life for patients and their families that emphasizes a holistic, all-person approach. After stroke, palliative care needs (eg, to address pain and physical, emotional, psychosocial, and spiritual distress) are insufficiently addressed by current models of care. Integrating palliative care principles is fundamental in all stages of stroke and should include strategies to improve communication about prognosis and goals of care, address psychosocial needs such as coping with loss, navigating complex health care systems, and preparing for death when necessary. We also review strategies to address the substantial inequities that exist across sociodemographic and regional strata in the use of life-sustaining treatment and access to specialists in stroke or palliative care.

CONCLUSIONS

Palliative care needs are common after stroke and should be addressed throughout the illness continuum. Research is urgently needed.

A scoping review of end-of-life discussions and palliative care: implications for neurological intensive care among Latinos in the U.S

Goals of care (Goals-of-care) discussions and palliative care (PC) are crucial to providing comprehensive healthcare, particularly for acute neurological conditions requiring admission to a neurological intensive care unit. We identified gaps in the literature and describe insight for future research on end-of-life discussions and PC for U.S. Latinos with acute neurological conditions. We searched 10 databases including peer-reviewed abstracts and manuscripts of hospitalized U.S. Latinos with acute neurological and non-neurological conditions. We included 44 of 3231 publications and identified various themes: PC utilization, pre-established advanced directives in Goals-of-care discussions, Goals-of-care discussion outcomes, tracheostomy or percutaneous gastrostomy tube placement rates among hospitalized Latinos. Our review highlights that Latinos appear to have lower palliative care utilization compared with non-Latino Whites and may be less likely to have pre-established advanced directives, more likely to have gastrostomy or tracheostomy placement and less likely to have do-not-resuscitate status.

How Do We Alleviate Long-Term Psychological Distress for Surrogate Decision Makers?

Our perspective as clinicians is focused on the patient; however, when patients present with severe stroke, we rely on family or surrogate decision-makers to assist with decisions regarding life-sustaining treatment. In this issue of Neurology®, Morgenstern et al.1 report on long-term psychological distress among surrogate decision-makers for patients with severe stroke. The authors used validated measures of post-traumatic stress, anxiety, and depression among family surrogate decision-makers and found between 17% and 28% of surrogates to have high scores on measures of psychological distress. One or more high levels of the psychological outcomes were found in 17%-43% of surrogates, 2 or more were found in 12%-27%, and all 3 were found in 5%-16% of surrogates. The study population included a biethnic community of predominantly nonimmigrant Mexican American (MA) and non-Hispanic White (NHW) persons, and outcomes were evaluated by ethnicity. Symptoms of post-traumatic stress remained worse among MA surrogates in the fully adjusted model; however, they were no longer significant for anxiety or depression after adjustment. The authors conclude that psychological distress is common among family surrogate decision-makers in the year after stroke and may be worse among MA surrogates. The authors propose that efforts are needed to support family members of all ethnic groups after severe stroke.