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

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(90%), oral medication (88%), parenteral nutrition (98%) and antibiotic therapy (86%) were either not ordered or withdrawn, however IV fluids were continued in all patients.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.