Principles of palliative care for patients with stroke
Stroke Foundation, 2021Holloway, 2014
Stroke and its sequelae present a number of palliative care issues; stroke is usually unexpected and sudden, and many patients do not have an advance care plan or clear goals of care.
Some patients with severe stroke die within hours or days, but sudden death after stroke can occur even after apparent initial stability. Initial prognostication of deterioration to death is difficult, but 9% of patients die during hospitalisationStroke Foundation, 2021, and 30 to 40% die in the first year after their stroke. Factors associated with higher risk of death and increased palliative care needs include:
- severe stroke
- haemorrhagic stroke
- large infarct or haematoma size
- decreased level of consciousness at admission
- multimorbidity, frailty or functional dependence before the stroke
- older ageMolidor, 2018.
Integrate a needs-focused approach to palliative care alongside disease-orientated management for stroke. At a minimum, provide the following aspects of palliative care:
- educate the patient and their carer(s) about prognosis, if appropriate—see Overview of communicating with and supporting patients with palliative care needs1
- determine goals of care with ongoing review and discussions with the patient (if possible) and their carer(s)
- support advance care planning, including the appointment of a substitute decision-maker
- support the family and carer.
The use of artificial feeding and other interventions may prolong life at the expense of unwanted disability and dependence on physical care. These issues need to be compassionately discussed and orientated to goals prior to the decisions to start or stop interventions—see Decisions about withdrawing or withholding treatment in palliative care. If poststroke treatments (eg enteral feeding, intravenous fluids) are stopped, dehydration can occur, which can decrease brain oedema and result in the patient waking up. Explain the nature of this temporary improvement to the family because it may be misinterpreted as the patient getting better.