title: End-of-life decisions in acute stroke patients: an observational cohort study.
abstract: BACKGROUND
  Crucial issues of modern stroke care include best practice end-of-life-decision (EOLD)-making procedures and the provision of high-quality palliative care for dying stroke patients.
  
  
  METHODS
  We retrospectively analyzed records of those patients who died over a 4-year period (2011-2014) on our Stroke Unit concerning EOLD, focusing on the factors that most probably guided decisions to induce limitation of life-sustaining therapy and subsequently end-of-life-care procedures thereafter.
  
  
  RESULTS
  Of all patients treated at our Stroke Unit, 120 (2.71%) died. In 101 (86.3%), a do-not-resuscitate-order (DNRO) was made during early treatment. A decision to withdraw/withhold further life supportive therapy was made in 40 patients (34.2%) after a mean of 5.0 days (range 0-29). Overall patient death occurred after a mean time of 7.0 days (range 1-30) and 2.6 days after therapy restrictions. Disturbance of consciousness at presentation, dysphagia on day 1 and large supratentorial stroke were possible indicators of decisions to therapeutic withdrawing/withholding. Proceedings of EOL care in these patients were heterogeneous; in most cases monitoring (95%), medical procedures (90%), oral medication (88%), parenteral nutrition (98%) and antibiotic therapy (86%) were either not ordered or withdrawn, however IV fluids were continued in all patients.
  
  
  CONCLUSIONS
  A high percentage of stroke patients were rated as terminally ill and died in the course of caregiving. Disturbance of consciousness at presentation, dysphagia on day 1 and large supratentorial stroke facilitated decisions to change therapeutic goals thus initiating end-of-life-care. However, there is further need to foster research on this field in order to ameliorate outcome prognostication, to understand the dynamics of EOLD-making procedures and to educate staff to provide high-quality patient-centred palliative care in stroke medicine.
authors.affiliation: Department of Neurology, UniversitätsMedizin Mannheim, University of Heidelberg, 68167, Mannheim, Germany. alonso@neuro.ma.uni-heidelberg.de.
authors.forename: Angelika
authors.initials: A
authors.lastname: Alonso
authors.affiliation: Department of Neurology, UniversitätsMedizin Mannheim, University of Heidelberg, 68167, Mannheim, Germany.
authors.forename: Anne D
authors.initials: AD
authors.lastname: Ebert
authors.affiliation: Health Care Ethics Committee, UniversitätsMedizin Mannheim, University of Heidelberg, 68167, Mannheim, Germany.
authors.forename: Dorothee
authors.initials: D
authors.lastname: Dörr
authors.affiliation: Department of Hematology and Oncology, UniversitätsMedizin Mannheim, University of Heidelberg, 68167, Mannheim, Germany.
authors.forename: Dieter
authors.initials: D
authors.lastname: Buchheidt
authors.affiliation: Department of Neurology, UniversitätsMedizin Mannheim, University of Heidelberg, 68167, Mannheim, Germany.
authors.forename: Michael G
authors.initials: MG
authors.lastname: Hennerici
authors.affiliation: Department of Neurology, UniversitätsMedizin Mannheim, University of Heidelberg, 68167, Mannheim, Germany.
authors.forename: Kristina
authors.initials: K
authors.lastname: Szabo
mesh_terms: D016223:Advance Directives / Q000523:psychology; D000368:Aged; D000369:Aged, 80 and over; D015331:Cohort Studies; D003657:Decision Making; D003661:Decision Support Techniques; D005260:Female; D006801:Humans; D008297:Male; D008875:Middle Aged; D012189:Retrospective Studies; D020521:Stroke / Q000401:mortality* / Q000523:psychology*; D013727:Terminal Care / Q000523:psychology*; D019452:Terminally Ill / Q000523:psychology; D028761:Withholding Treatment
keywords: Advance directives; End-of-life decisions; Palliative care; Stroke; Stroke mortality