The Lack of Documentation of Preferences in a Cohort of Adults Who Died After Ischemic Stroke

Published in: Neurology, 2016

Posted on RAND.org on April 22, 2016

by Maisha T. Robinson, Barbara Vickrey, Robert G. Holloway, Kelly Chong, Linda S. Williams, Robert H. Brook, Mei Leng, Punam Parikh, David Zingmond

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Research Question

  1. What proportion of stroke patients discussed their preferences regarding life-sustaining interventions with physicians?

OBJECTIVE: To measure the extent and timing of physicians' documentation of communication with patients and families regarding limitations on life-sustaining interventions, in a population cohort of adults who died within 30 days after hospitalization for ischemic stroke. METHODS: We used the California Office of Statewide Health Planning and Development Patient Discharge Database to identify a retrospective cohort of adults with ischemic strokes at all California acute care hospitals from December 2006 to November 2007. Of 326 eligible hospitals, a representative sample of 39 was selected, stratified by stroke volume and mortality. Medical records of 981 admissions were abstracted, oversampled on mortality and tissue plasminogen activator receipt. Among 198 patients who died by 30 days postadmission, overall proportions and timing of documented preferences were calculated; factors associated with documentation were explored. RESULTS: Of the 198 decedents, mean age was 80 years, 78% were admitted from home, 19% had mild strokes, 11% received tissue plasminogen activator, and 42% died during the index hospitalization. Preferences about at least one life-sustaining intervention were recorded on 39% of patients: cardiopulmonary resuscitation 34%, mechanical ventilation 23%, nasogastric tube feeding 10%, and percutaneous enteral feeding 6%. Most discussions occurred within 5 days of death. Greater stroke severity was associated with increased in-hospital documentation of preferences (p < 0.05). CONCLUSIONS: Documented discussions about limitations on life-sustaining interventions during hospitalization were low, even though this cohort died within 30 days poststroke. Improving the documentation of preferences may be difficult given the 2015 Centers for Medicare and Medicaid 30-day stroke mortality hospital performance measure that is unadjusted for patient preferences regarding life-sustaining interventions.

Key Findings

  • Frequency of patient-doctor discussions regarding intervention preferences was less than optimal.
  • Discussions were more likely to have happened in cases with higher stroke severity.
  • Systematically documenting patient preferences could help increase the frequency of these conversations happening and thereby improve care quality.
  • Hospital quality measures that require reporting of 30-day mortality after a stroke but do not adjust for patient end-of-life preferences and stroke severity could have unintended consequences.

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