title: Early stroke mortality, patient preferences, and the withdrawal of care bias.
abstract: OBJECTIVE
  Early mortality is a potential measure of the quality of care provided to hospitalized stroke patients. Whether in-hospital stroke mortality is reflective of deviations from evidence-based practices or patient/family preferences on life-sustaining measures is unclear.
  
  
  METHODS
  All ischemic stroke mortalities at an academic medical center were reviewed to better understand the causes of inpatient stroke mortality.
  
  
  RESULTS
  Among 37 deaths or discharges to hospice in 2009, 36 occurred after a patient/family decision to withdraw/withhold potentially life-sustaining interventions. An independent survey of 3 vascular neurologists revealed that some early deaths could have been delayed beyond 30 days if patients or families had agreed to more aggressive measures. From these data, we estimate the magnitude of a "withdrawal of care" bias to be approximately 40% of the observed short-term mortality.
  
  
  CONCLUSIONS
  Acute stroke mortality may be more reflective of patient/family preferences than the provision of evidence-based care.
authors.affiliation: Department of Neurology, University of Rochester Medical Center, Rochester, NY, USA. Adam_Kelly@urmc.rochester.edu
authors.forename: Adam G
authors.initials: AG
authors.lastname: Kelly
authors.forename: Kathryn D
authors.initials: KD
authors.lastname: Hoskins
authors.forename: Robert G
authors.initials: RG
authors.lastname: Holloway
mesh_terms: D000328:Adult; D024362:Advance Directive Adherence; D000367:Age Factors; D000368:Aged; D000369:Aged, 80 and over; D002545:Brain Ischemia / Q000401:mortality; D016887:Cardiopulmonary Resuscitation; D002423:Cause of Death; D015897:Comorbidity; D019317:Evidence-Based Medicine; D005190:Family; D005260:Female; D005343:Fibrinolytic Agents / Q000627:therapeutic use; D017052:Hospital Mortality; D006801:Humans; D038801:International Classification of Diseases; D008021:Life Support Systems; D008297:Male; D008875:Middle Aged; D057240:Patient Preference; D020521:Stroke / Q000150:complications / Q000401:mortality* / Q000628:therapy; D010959:Tissue Plasminogen Activator / Q000627:therapeutic use; D028761:Withholding Treatment / Q000706:statistics & numerical data*
chemical_list: D005343:Fibrinolytic Agents; D010959:Tissue Plasminogen Activator