Objective: Early mortality is a potential measure of the quality of care provided to hospitalized stroke patients. Whether in-hospital stroke mortality is reflective of deviations from evidencebased practices or patient/family preferences on life-sustaining measures is unclear.Methods: All ischemic stroke mortalities at an academic medical center were reviewed to better understand the causes of inpatient stroke mortality.Results: Among 37 deaths or discharges to hospice in 2009, 36 occurred after a patient/family decision to withdraw/withhold potentially life-sustaining interventions. An independent survey of 3 vascular neurologists revealed that some early deaths could have been delayed beyond 30 days if patients or families had agreed to more aggressive measures. From these data, we estimate the magnitude of a "withdrawal of care" bias to be approximately 40% of the observed short-term mortality.Conclusions: Acute stroke mortality may be more reflective of patient/family preferences than the provision of evidence-based care. Neurology Mortality has increasingly been used as a measure of the quality of care provided to stroke patients.1 However, it has been shown to be inconsistent across multiple evaluating systems and is overly reliant on proprietary risk-adjustment methods. Despite this, the Center for Medicare and Medicaid Services (CMS) is developing a 30-day risk-adjusted stroke mortality measure for public reporting purposes.Whether inpatient stroke mortality is reflective of evidence-based practice is uncertain. Hospital-based deaths may arise from unsafe practices, deviations from standards of care, or progression of the underlying disease. Deaths also occur when patients or families elect to withhold or withdraw life-sustaining interventions, thereby allowing a natural death rather than prolonging life in a state deemed unacceptable to the patient. These choices may be guided by written advanced directives or discussions with surrogates, suggesting an informed, patient-centered decision. Research has shown that the majority of deaths on an inpatient neurology service resulted from withdrawal of life-sustaining support at the patient/family request.2 In addition, involvement of palliative care services is common after stroke, 3 especially among higher educated patients. 4 We conducted a review of ischemic stroke mortalities at our institution to better describe the manner in which deaths occur after stroke, and estimate the potential impact that decisions to withhold/ withdraw treatments have on short-term ischemic stroke mortality. Specifically: What are the characteristics of stroke patients who die? How do stroke patients die-are deaths due to deviations from evidence-based practices? How much could early stroke mortality be affected by decisions to withhold/ withdraw life-sustaining measures?
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