A review of stroke deaths at one hospital highlights the substantial effect that family decisions about life support have on stroke mortality.

Stroke mortality is being considered in models to measure quality of care in hospitals. Some evidence suggests that unmeasured factors such as stroke severity can affect mortality (JW Neurol Aug 7 2012). Now, researchers have examined the effect that withdrawal of life-sustaining treatments has on short-term stroke mortality, by investigating the 37 stroke deaths that occurred at one hospital or during postdischarge hospice care in 2009.

Of the 37 deaths, 36 occurred after avoidance or withdrawal of life support, based on the patient’s or family’s decision. Three neurologists at the center who were not otherwise involved in the study judged that about 40% of these short-term deaths might have been avoided if life support had been used or continued for patients with borderline or better prospects for survival (4.6% mortality vs. 7.8%). Care of these patients adhered to 98% of four standard-of-care measures.

— The Editors

Comment: Vascular neurologists have traditionally been wary of the value of acute stroke mortality as a quality measure. Because aggressive care can sometimes result in patients surviving the acute (30-day poststroke) period, but with severe disability, would the result be acceptable to patients and their families?

This study demonstrates the impact that clinician decisions about withdrawal of care have on stroke mortality. The vast majority of deaths after ischemic stroke were caused by withdrawal of mechanical ventilation or artificial nutrition methods, not by deviations from standard care metrics. The authors do not comment on the proportion of patients that underwent hemicraniectomy, a procedure with proven value for reducing stroke mortality. In an era of finite healthcare resources, one hopes that hospitals will not pursue hyperaggressive care just to make sure that the 30-day stroke mortality appears low.

Source: Journal Watch Neurology