Palliative approach in acute neurological events: a five-year study

Abstract

INTRODUCTION: Acute neurological illness often results in severe disability. Five-year life expectancy is around 40%; half the survivors become completely dependent on outside help. OBJECTIVE: Evaluate the symptoms of patients admitted to a Hospital ward with a diagnosis of stroke, subarachnoid hemorrhage or subdural hematoma, and analyze the role of an In-Hospital Palliative Care Support Team. MATERIAL AND METHODS: Retrospective, observational study with a sample consisting of all patients admitted with acute neurological illness and with a guidance request made to the In-Hospital Palliative Care Support Team of a tertiary Hospital, over 5 years (2012)(2013)(2014)(2015)(2016).RESULTS: A total of 66 patients were evaluated, with an age median of 83 years old. Amongst them, there were 41 ischaemic strokes, 12 intracranial bleedings, 12 subdural hematomas, and 5 subarachnoid hemorrhages. The median of delay between admission and guidance request was 14 days. On the first evaluation by the team, the GCS score median was 6/15 and the Palliative Performance Scale (PPS) median 10%. Dysphagia (96.8%) and bronchorrhea (48.4%) were the most prevalent symptoms. A total of 56 patients had a feeding tube (84.8%), 33 had vital sign monitoring (50.0%), 24 were hypocoagulated (36.3%), 25 lacked opioid or anti-muscarinic therapy for symptom control (37,9%); 6 patients retained orotracheal intubation, which was removed. In-hospital mortality was 72.7% (n=48). DISCUSSION AND CONCLUSION:Patients were severely debilitated, in many cases futile interventions persisted, yet several were under-medicated for symptom control. The delay between admission and collaboration request was high. Due to the high morbidity associated with acute neurological illness, palliative care should always be timely provided.

Palliative care after stroke: A review

“… 4 , 10 – 17 These included retrospective cohorts, 10 , 11 a retrospective registry study, 12 a national clinical audit, 13 retrospective case note studies, 14 , 15 a qualitative study with healthcare professionals, 16 cross-sectional face-to-face survey, 17 and one mixed methods longitudinal study. 4 Four studies 4 , 10 , 11 , 17 collected data on stroke survivors/decedents in their own homes, six were hospital based, 4 , 12 – 16 and two were from nursing homes. The studies were from US, 10 , 11 Europe (UK, Ireland), 4 , 14 Sweden, 12 Portugal, 15 Australia, 13 and India.…”

“… 4 Four studies 4 , 10 , 11 , 17 collected data on stroke survivors/decedents in their own homes, six were hospital based, 4 , 12 – 16 and two were from nursing homes. The studies were from US, 10 , 11 Europe (UK, Ireland), 4 , 14 Sweden, 12 Portugal, 15 Australia, 13 and India. 16 , 17 Three 10 – 13 report large cohorts of stroke patients which were subsets of larger palliative care cohorts.…”

“…The most frequently recorded needs were dysphagia (96.8%), 15 death rattles (31.5–60.7%), dyspnea (16.3–48.4%), and pain (30.3–42.7%). 12 , 14 , 15 Two studies 14 , 15 reported anxiety (12.9–18.9% ) and confusion or delirium (7.9–19.4%), while one 14 reported agitation (25.9%). Other symptoms included constipation, dry mouth, and seizures.…”

“…Other symptoms included constipation, dry mouth, and seizures. 15 After hospital discharge, pain affected 50%, numbness or tingling 48%, sleep disturbance 43%, and nausea/vomiting and bladder/bowel incontinence affected 15%. 17 In a large US cohort 10 , 11 receiving home hospice care, stroke was a common cause of fecal 10 or urinary incontinence.…”

“…Swedish healthcare professionals were less likely to know if end-of-life symptoms were present in stroke patients than in cancer patients, or to know if stroke patients’ preferences regarding place of care had been met. 12 Cognitive impairment, aphasia, and dysarthria were barriers to pain assessment 15 , 16 and accessing services. 4 The largest studies of palliative care needs after stroke were from specialist palliative care settings 10 , 11 , 13 or unspecified hospital or care home settings, 12 and so cannot easily be generalized to a broader stroke population.…”