title: Care-limiting decisions in acute stroke and association with survival: analyses of UK national quality register data.
abstract: BACKGROUND
  Prognosis after intracerebral hemorrhage (ICH) is poor and care-limiting decisions may worsen outcomes.
  
  
  OBJECTIVE
  To determine whether in current UK stroke practice, key acute care decisions are associated with stroke subtype (ICH/ischemic) and whether these decisions are independently associated with survival.
  
  
  METHODS
  We extracted data describing all stroke patients included in a UK quality register between 1 April 2013 and 31 March 2014. Key care decisions in our analyses were transfer to higher level care on admission and palliation in the first 72 h. We used multivariable regression models to test for associations between stroke subtype (ICH/ischemic), key care decisions, and survival.
  
  
  RESULTS
  A total of 65,818 patients were included in the final analysis. After ICH (n = 7020/65,818, 10.7%), 10.5% were palliated on the day of admission and 19.3% by 72 h (vs. 0.7% and 3.3% for ischemic stroke). Although a greater proportion were admitted directly to higher level care after ICH (3.7% vs. 1.5% for ischemic stroke), ICH was not independently associated with the decision to admit to higher level care (adjusted odds ratio (OR): 1.12, 95% confidence interval (95%CI): 0.95-1.31, p = 0.183). However, ICH was strongly associated with the decision to commence palliative care on the day of admission (OR: 7.27, 95%CI: 6.31-8.37, p < 0.001). Palliative care was independently associated with risk of death by 30 days regardless of stroke subtype.
  
  
  CONCLUSIONS
  When compared to ischemic stroke, patients with ICH are much more likely to commence palliative care during the first 72 h of their care, independent of level of consciousness, age, and premorbid health.
authors.affiliation: Manchester Academic Health Sciences Centre, Salford Royal NHS Foundation Trust, UK adrian.parry-jones@manchester.ac.uk.
authors.forename: Adrian R
authors.initials: AR
authors.lastname: Parry-Jones
authors.affiliation: Royal College of Physicians, London, UK.
authors.forename: Lizz
authors.initials: L
authors.lastname: Paley
authors.affiliation: Division of Health and Social Care Research, Kings College London, UK.
authors.forename: Benjamin D
authors.initials: BD
authors.lastname: Bray
authors.affiliation: Royal College of Physicians, London, UK.
authors.forename: Alex M
authors.initials: AM
authors.lastname: Hoffman
authors.affiliation: Royal Devon and Exeter NHS Foundation Trust, UK.
authors.forename: Martin
authors.initials: M
authors.lastname: James
authors.affiliation: St George's University Hospitals NHS Foundation Trust, UK.
authors.forename: Geoffrey C
authors.initials: GC
authors.lastname: Cloud
authors.affiliation: Manchester Academic Health Sciences Centre, Salford Royal NHS Foundation Trust, UK.
authors.forename: Pippa J
authors.initials: PJ
authors.lastname: Tyrrell
authors.affiliation: Royal College of Physicians, London, UK Division of Health and Social Care Research, Kings College London, UK Guy's and St Thomas' NHS Foundation Trust, UK.
authors.forename: Anthony G
authors.initials: AG
authors.lastname: Rudd
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D002543:Cerebral Hemorrhage / Q000175:diagnosis* / Q000401:mortality; D000066491:Clinical Decision-Making; D003422:Critical Care / Q000379:methods; D005260:Female; D006801:Humans; D008297:Male; D008875:Middle Aged; D011379:Prognosis; D012042:Registries; D020521:Stroke / Q000175:diagnosis* / Q000401:mortality; D016019:Survival Analysis; D006113:United Kingdom
keywords: Ischemic stroke; critical care; intracerebral hemorrhage; palliative care; prognosis