Impact of a clinical pathway on end-of-life care following stroke: A mixed methods study

Cowey, Eileen; Smith, Lawrence D.; Stott, David J.; McAlpine, Christine; Mead, Gillian; Barber, Mark; Walters, Matthew

doi:10.1177/0269216314551378

Cited by 20 publications

(14 citation statements)

References 41 publications

Supporting

Mentioning

Contrasting

Order By: Relevance

“…The treating physician carries the final responsibility for medical treatment decisions in incapacitated patients. It can be an enormous emotional burden for legal representatives to feel the sole responsibility for treatment restrictions and it is therefore essential to avoid giving families the impression they are being asked to make these major decisions on their own [ 29 – 31 ].…”

Section: Discussionmentioning

confidence: 99%

Advance directives, proxy opinions, and treatment restrictions in patients with severe stroke

et al. 2017

View full text Add to dashboard Cite

BackgroundPatients with severe stroke often do not have the capacity to participate in discussions on treatment restrictions because of a reduced level of consciousness, aphasia, or another cognitive disorder. We assessed the role of advance directives and proxy opinions in the decision-making process of incapacitated patients.MethodsSixty patients with severe functional dependence (Barthel Index ≤6) at day four after ischemic stroke or intracerebral hemorrhage were included in a prospective two-center cohort study. The decision-making process with respect to treatment restrictions was assessed by means of a semi-structured questionnaire administered to the treating physician at the day of inclusion.ResultsForty-nine patients (82%) did not have the capacity to participate in the decision-making process. In eight patients, there was no discussion on treatment restrictions and full care was installed. In 41 patients, the decision whether to install treatment restrictions was discussed with proxies. One patient had a written advance directive. In the remaining 40 patients, proxies based their opinion on previously expressed wishes of the patient (18 patients) or advised in the best interest of the patient (22 patients). In 36 of 41 patients, treatment restrictions were installed after agreement between physician and proxy. At six months, 23 of 49 patients had survived. In only three of them the decision on treatment restrictions was based on previously expressed wishes. Remarkably, two of these survivors could not recall any of their alleged previously expressed wishes.ConclusionsTreatment restrictions were installed in the majority of incapacitated patients after stroke. Proxy opinions frequently served as the best way to respect the patients’ autonomy, but their accuracy remains unclear.Electronic supplementary materialThe online version of this article (10.1186/s12904-017-0234-8) contains supplementary material, which is available to authorized users.

show abstract

Section: Discussionmentioning

confidence: 99%

Advance directives, proxy opinions, and treatment restrictions in patients with severe stroke

et al. 2017

View full text Add to dashboard Cite

show abstract

“…To date, there is a broad consensus that there is an enormous but still underestimated need for palliative care in dying stroke patients [ 13 – 15 ]. Whereas end-of-life care is well established in diseases such as cancer or advanced heart disease, research on end-of-life care has been relatively neglected in stroke populations and evaluation of end-of-life care processes in stroke has to date been very limited [ 16 – 18 ]. Moreover, the palliative care needs of acute stroke patients may be very different from those in advanced stages of other chronic diseases [ 19 ].…”

Section: Introductionmentioning

confidence: 99%

End-of-life decisions in acute stroke patients: an observational cohort study

et al. 2016

View full text Add to dashboard Cite

BackgroundCrucial issues of modern stroke care include best practice end-of-life-decision (EOLD)-making procedures and the provision of high-quality palliative care for dying stroke patients.MethodsWe retrospectively analyzed records of those patients who died over a 4-year period (2011–2014) on our Stroke Unit concerning EOLD, focusing on the factors that most probably guided decisions to induce limitation of life-sustaining therapy and subsequently end-of-life-care procedures thereafter.ResultsOf all patients treated at our Stroke Unit, 120 (2.71 %) died. In 101 (86.3 %), a do-not-resuscitate-order (DNRO) was made during early treatment. A decision to withdraw/withhold further life supportive therapy was made in 40 patients (34.2 %) after a mean of 5.0 days (range 0–29). Overall patient death occurred after a mean time of 7.0 days (range 1–30) and 2.6 days after therapy restrictions. Disturbance of consciousness at presentation, dysphagia on day 1 and large supratentorial stroke were possible indicators of decisions to therapeutic withdrawing/withholding. Proceedings of EOL care in these patients were heterogeneous; in most cases monitoring (95 %), medical procedures (90 %), oral medication (88 %), parenteral nutrition (98 %) and antibiotic therapy (86 %) were either not ordered or withdrawn, however IV fluids were continued in all patients.ConclusionsA high percentage of stroke patients were rated as terminally ill and died in the course of caregiving. Disturbance of consciousness at presentation, dysphagia on day 1 and large supratentorial stroke facilitated decisions to change therapeutic goals thus initiating end-of-life-care. However, there is further need to foster research on this field in order to ameliorate outcome prognostication, to understand the dynamics of EOLD-making procedures and to educate staff to provide high-quality patient-centred palliative care in stroke medicine.Electronic supplementary materialThe online version of this article (doi:10.1186/s12904-016-0113-8) contains supplementary material, which is available to authorized users.

show abstract

“…26 In stroke, bereaved relatives reported that while staff discussed with them the likelihood of early death after stroke, they were unprepared for a prolonged dying process. 13 In our study, some professionals said they felt that patients and families did not like being told that the future was uncertain, and this appeared to stop them talking about prognostic uncertainty effectively.…”

Section: Strengths and Weaknesses/limitations Of The Studymentioning

confidence: 76%

“…Two recent studies have explored the views and experiences of patients and carers in some depth. 13,19 We attempted to optimise response rates by ensuring that the survey was short, indicating in a covering email the likely time required for completion, embedding the survey link in the email and sending an email reminder after 2 weeks. 20 Survey Monkey automatically anonymised the data and provided the number of responses in each category.…”

Section: Methodsmentioning

confidence: 99%

The Key Challenges of Discussing End-Of-Life Stroke Care with Patients and Families: A Mixed-Methods Electronic Survey of Hospital and Community Healthcare Professionals

Doubal

Cowey

Bailey³

et al. 2018

Journal of the Royal College of Physicians of Edinburgh

View full text Add to dashboard Cite

show abstract

Impact of a clinical pathway on end-of-life care following stroke: A mixed methods study

Cited by 20 publications

References 41 publications

Advance directives, proxy opinions, and treatment restrictions in patients with severe stroke

Advance directives, proxy opinions, and treatment restrictions in patients with severe stroke

End-of-life decisions in acute stroke patients: an observational cohort study

The Key Challenges of Discussing End-Of-Life Stroke Care with Patients and Families: A Mixed-Methods Electronic Survey of Hospital and Community Healthcare Professionals

Contact Info

Product

Resources

About