Early stroke mortality, patient preferences, and the withdrawal of care bias

Abstract

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?

Declining mortality in neurocritical care patients: a cohort study in Southern Alberta over eleven years

“…58,59 Opinions concerning the prognosis of neurocritical care patients vary among critical care practitioners. This variability may lead to significant differences in withdrawal-of-care practices, [60][61][62][63][64] which in turn may explain some of the marked variability in outcomes that has been described, even within Canada. 54,60 Some research has suggested that physicians may be generally more pessimistic about the prognosis of neurocritical care patients than is justified by their particular clinical characteristics.…”

Current practices in feeding tube placement for US acute ischemic stroke inpatients

“…However, these differences may also result from diversity in preferences or disparities in how providers and institutions interpret these preferences. 24,25 Our study is limited in that it lacks data on patient or family preferences and understanding and the scope of provider discussions with patients and families.…”

Impact of Language Barriers on Stroke Care and Outcomes

“…This reduction in mortality risk was attenuated by differences between groups in the desire for aggressive versus supportive medical care, and previous studies have suggested that early stroke mortality is strongly sensitive to patient/family preferences for withdrawal of care. 13 As further evidence of this preference for active treatment, patients with language barriers were more likely to be discharged with a residual neurological deficit, had longer lengths of stay, and were more likely to be discharged to home or to a rehabilitation hospital rather than to another acute care or a long-term care institution. Patients with language barriers also performed better on several inhospital quality of care markers: they were more likely to receive timely brain imaging, and were more likely to receive assessments from paramedical personnel.…”