In this study, inpatient ischemic stroke mortality was highly sensitive to patient and family preferences, and deaths occurred almost exclusively after limitations on potentially life-sustaining measures. Decisions to withdraw/withhold interventions that might prevent or postpone mortality may have considerable effects on hospital-based mortality rates; our estimates suggest that inpatient stroke mortality may be affected by more than 40%. These mortalities occurred in the setting of high adherence to stroke process measures, suggesting that deaths can occur despite the provision of high-quality, evidence-based care. This is consistent with previous data showing that adherence to performance measures correlates poorly with short-term mortality after myocardial infarction.6
IV tPA or other attempts at reperfusion therapy were used in over one-third of patients in this study, well above the average reported treatment rates of 3% to 5%.7
Less than 30% of patients had early limitations of care as evidenced by DNR orders prior to the second hospital day, which has been considered a possible proxy of less aggressive care in prior studies.8,9
In addition, withdrawal of MV or AHN was much more common than withholding these treatments (25 patients vs 11, respectively), so the majority of patients received at least a trial of life-sustaining interventions to allow for potential neurologic recovery. Therefore, in this population, deaths are unlikely to be explained by an overall lack of urgency or aggressiveness in the early care of stroke patients.
Short-term mortality rates can be improved by the more routine provision of life-sustaining interventions,10
but at the cost of patients being left in disabled states that might be against their wishes. Conversely, choosing a palliative approach early after stroke may prevent the opportunity for significant recovery and adaptation of patients and families to neurologic deficits. This decision process is further complicated by the relative lack of early prognostic signs (clinical or radiographic) in ischemic stroke that are highly predictive of a universally poor outcome.11
This study analyzes outcomes from a single large academic medical center. There is likely to be some variation in the rate of withdrawal/withholding decisions across different institutions, depending on patient case mix, hospital size, academic status, geographic location, economic considerations (from the patient/family and medical center perspective), and other factors. We challenge other centers to critically evaluate their early stroke mortalities to further increase data in this area.
Our attempt to quantify a “withdrawal of care bias” is dependent on the opinions of 3 neurologists with clinical expertise in caring for stroke patients. Estimates of surviving to 30 days if no interventions were withdrawn/withheld might be considerably different if other providers (e.g., neurointensivists, internal medicine hospitalists) had been surveyed instead. Therefore, the effect of withdrawal/withholding of care on early stroke mortality may be greater than or less than our estimate. The variability in how different providers offer prognoses after ischemic stroke warrants further study, especially since patients and families may be deciding to withhold or withdraw interventions based, at least in part, on these predictions.12
Given the retrospective nature of our study, the specific manner in which details regarding prognosis for recovery, likelihood of disability, and other critical elements in the decision-making process cannot be determined.
Current attempts by the Center for Medicare and Medicaid Services to develop a hospital-based, 30-day stroke mortality measure are ongoing. The proposed measure has come under scrutiny during a public comment period13
for 1) the inability to account for initial stroke severity, which is the strongest predictor of early stroke mortality14
; and 2) the inability to discern deaths due to deviations in standards of care from those deaths that occur after withdrawing or withholding life-sustaining measures in a palliative care setting. The results of our study substantiate these concerns; nearly all deaths occurred after a decision to withdraw/withhold interventions in a population with high initial stroke severity (as measured by the NIHSS).
The goal of the proposed CMS measure, like most publicly reported measures, is to improve transparency and hospital accountability in order to improve outcomes. But will it improve the actual care that is being provided to stroke patients? There are well-reported unintended consequences of publicly reported outcomes data,15
and one could argue that providers might be more apt to suggest MV or AHN to stroke patients or their families in fear of “failing” the CMS measure. If providers allow their personal or other motivations (consciously or unconsciously) to intrude on patient-centered decisions regarding life-sustaining interventions, therein lies the true failure.
Short-term stroke mortality is highly dependent on patient/family preferences regarding goals of care, and this sensitivity should give us pause in using short-term stroke mortality as a primary marker of quality of care. Measures of decisional quality (accounting for personal preferences) should be developed to ensure that the provision of care is patient and family-centered, even under circumstances where there is little or no hope for recovery.16
We recommend that time-limited trials be utilized in situations where the clinical outcome or patient preferences are uncertain.