title: The lack of documentation of preferences in a cohort of adults who died after ischemic stroke.
abstract: 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.
  
  
  
  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.
  
  
  
  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).
  
  
  
  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.
authors.affiliation: From the Department of Neurology (M.T.R.), Mayo Clinic, Jacksonville, FL; Department of Neurology (B.G.V.), David Geffen UCLA School of Medicine (R.H.B.), and Department of Medicine, Division of General Internal Medicine and Health Services Research (M.L., P.P., D.S.Z.), University of California, Los Angeles; Icahn School of Medicine at Mount Sinai (B.G.V.), New York; Department of Neurology (R.G.H.), University of Rochester, New York, NY; University of New Mexico School of Medicine (K.C.); Veterans Affairs HSR&D Center for Health Information and Communication (L.S.W.); Department of Neurology, Indiana University (L.S.W.); Regenstrief Institute, Inc. (L.S.W.); RAND Corporation (R.H.B.); Jonathan and Karin Fielding School of Public Health (R.H.B.); and Veterans Affairs Greater Los Angeles Healthcare System (D.S.Z.). robinson.maisha@mayo.edu.
authors.forename: Maisha T
authors.initials: MT
authors.lastname: Robinson
authors.affiliation: From the Department of Neurology (M.T.R.), Mayo Clinic, Jacksonville, FL; Department of Neurology (B.G.V.), David Geffen UCLA School of Medicine (R.H.B.), and Department of Medicine, Division of General Internal Medicine and Health Services Research (M.L., P.P., D.S.Z.), University of California, Los Angeles; Icahn School of Medicine at Mount Sinai (B.G.V.), New York; Department of Neurology (R.G.H.), University of Rochester, New York, NY; University of New Mexico School of Medicine (K.C.); Veterans Affairs HSR&D Center for Health Information and Communication (L.S.W.); Department of Neurology, Indiana University (L.S.W.); Regenstrief Institute, Inc. (L.S.W.); RAND Corporation (R.H.B.); Jonathan and Karin Fielding School of Public Health (R.H.B.); and Veterans Affairs Greater Los Angeles Healthcare System (D.S.Z.).
authors.forename: Barbara G
authors.initials: BG
authors.lastname: Vickrey
authors.affiliation: From the Department of Neurology (M.T.R.), Mayo Clinic, Jacksonville, FL; Department of Neurology (B.G.V.), David Geffen UCLA School of Medicine (R.H.B.), and Department of Medicine, Division of General Internal Medicine and Health Services Research (M.L., P.P., D.S.Z.), University of California, Los Angeles; Icahn School of Medicine at Mount Sinai (B.G.V.), New York; Department of Neurology (R.G.H.), University of Rochester, New York, NY; University of New Mexico School of Medicine (K.C.); Veterans Affairs HSR&D Center for Health Information and Communication (L.S.W.); Department of Neurology, Indiana University (L.S.W.); Regenstrief Institute, Inc. (L.S.W.); RAND Corporation (R.H.B.); Jonathan and Karin Fielding School of Public Health (R.H.B.); and Veterans Affairs Greater Los Angeles Healthcare System (D.S.Z.).
authors.forename: Robert G
authors.initials: RG
authors.lastname: Holloway
authors.affiliation: From the Department of Neurology (M.T.R.), Mayo Clinic, Jacksonville, FL; Department of Neurology (B.G.V.), David Geffen UCLA School of Medicine (R.H.B.), and Department of Medicine, Division of General Internal Medicine and Health Services Research (M.L., P.P., D.S.Z.), University of California, Los Angeles; Icahn School of Medicine at Mount Sinai (B.G.V.), New York; Department of Neurology (R.G.H.), University of Rochester, New York, NY; University of New Mexico School of Medicine (K.C.); Veterans Affairs HSR&D Center for Health Information and Communication (L.S.W.); Department of Neurology, Indiana University (L.S.W.); Regenstrief Institute, Inc. (L.S.W.); RAND Corporation (R.H.B.); Jonathan and Karin Fielding School of Public Health (R.H.B.); and Veterans Affairs Greater Los Angeles Healthcare System (D.S.Z.).
authors.forename: Kelly
authors.initials: K
authors.lastname: Chong
authors.affiliation: From the Department of Neurology (M.T.R.), Mayo Clinic, Jacksonville, FL; Department of Neurology (B.G.V.), David Geffen UCLA School of Medicine (R.H.B.), and Department of Medicine, Division of General Internal Medicine and Health Services Research (M.L., P.P., D.S.Z.), University of California, Los Angeles; Icahn School of Medicine at Mount Sinai (B.G.V.), New York; Department of Neurology (R.G.H.), University of Rochester, New York, NY; University of New Mexico School of Medicine (K.C.); Veterans Affairs HSR&D Center for Health Information and Communication (L.S.W.); Department of Neurology, Indiana University (L.S.W.); Regenstrief Institute, Inc. (L.S.W.); RAND Corporation (R.H.B.); Jonathan and Karin Fielding School of Public Health (R.H.B.); and Veterans Affairs Greater Los Angeles Healthcare System (D.S.Z.).
authors.forename: Linda S
authors.initials: LS
authors.lastname: Williams
authors.affiliation: From the Department of Neurology (M.T.R.), Mayo Clinic, Jacksonville, FL; Department of Neurology (B.G.V.), David Geffen UCLA School of Medicine (R.H.B.), and Department of Medicine, Division of General Internal Medicine and Health Services Research (M.L., P.P., D.S.Z.), University of California, Los Angeles; Icahn School of Medicine at Mount Sinai (B.G.V.), New York; Department of Neurology (R.G.H.), University of Rochester, New York, NY; University of New Mexico School of Medicine (K.C.); Veterans Affairs HSR&D Center for Health Information and Communication (L.S.W.); Department of Neurology, Indiana University (L.S.W.); Regenstrief Institute, Inc. (L.S.W.); RAND Corporation (R.H.B.); Jonathan and Karin Fielding School of Public Health (R.H.B.); and Veterans Affairs Greater Los Angeles Healthcare System (D.S.Z.).
authors.forename: Robert H
authors.initials: RH
authors.lastname: Brook
authors.affiliation: From the Department of Neurology (M.T.R.), Mayo Clinic, Jacksonville, FL; Department of Neurology (B.G.V.), David Geffen UCLA School of Medicine (R.H.B.), and Department of Medicine, Division of General Internal Medicine and Health Services Research (M.L., P.P., D.S.Z.), University of California, Los Angeles; Icahn School of Medicine at Mount Sinai (B.G.V.), New York; Department of Neurology (R.G.H.), University of Rochester, New York, NY; University of New Mexico School of Medicine (K.C.); Veterans Affairs HSR&D Center for Health Information and Communication (L.S.W.); Department of Neurology, Indiana University (L.S.W.); Regenstrief Institute, Inc. (L.S.W.); RAND Corporation (R.H.B.); Jonathan and Karin Fielding School of Public Health (R.H.B.); and Veterans Affairs Greater Los Angeles Healthcare System (D.S.Z.).
authors.forename: Mei
authors.initials: M
authors.lastname: Leng
authors.affiliation: From the Department of Neurology (M.T.R.), Mayo Clinic, Jacksonville, FL; Department of Neurology (B.G.V.), David Geffen UCLA School of Medicine (R.H.B.), and Department of Medicine, Division of General Internal Medicine and Health Services Research (M.L., P.P., D.S.Z.), University of California, Los Angeles; Icahn School of Medicine at Mount Sinai (B.G.V.), New York; Department of Neurology (R.G.H.), University of Rochester, New York, NY; University of New Mexico School of Medicine (K.C.); Veterans Affairs HSR&D Center for Health Information and Communication (L.S.W.); Department of Neurology, Indiana University (L.S.W.); Regenstrief Institute, Inc. (L.S.W.); RAND Corporation (R.H.B.); Jonathan and Karin Fielding School of Public Health (R.H.B.); and Veterans Affairs Greater Los Angeles Healthcare System (D.S.Z.).
authors.forename: Punam
authors.initials: P
authors.lastname: Parikh
authors.affiliation: From the Department of Neurology (M.T.R.), Mayo Clinic, Jacksonville, FL; Department of Neurology (B.G.V.), David Geffen UCLA School of Medicine (R.H.B.), and Department of Medicine, Division of General Internal Medicine and Health Services Research (M.L., P.P., D.S.Z.), University of California, Los Angeles; Icahn School of Medicine at Mount Sinai (B.G.V.), New York; Department of Neurology (R.G.H.), University of Rochester, New York, NY; University of New Mexico School of Medicine (K.C.); Veterans Affairs HSR&D Center for Health Information and Communication (L.S.W.); Department of Neurology, Indiana University (L.S.W.); Regenstrief Institute, Inc. (L.S.W.); RAND Corporation (R.H.B.); Jonathan and Karin Fielding School of Public Health (R.H.B.); and Veterans Affairs Greater Los Angeles Healthcare System (D.S.Z.).
authors.forename: David S
authors.initials: DS
authors.lastname: Zingmond
mesh_terms: D000369:Aged, 80 and over; D002545:Brain Ischemia / Q000401:mortality / Q000523:psychology / Q000628:therapy*; D002140:California; D003142:Communication; D004282:Documentation; D006760:Hospitalization; D006801:Humans; D008020:Life Support Care; D008499:Medical Records; D057240:Patient Preference; D010817:Physician-Patient Relations; D016414:Resuscitation Orders; D012189:Retrospective Studies; D020521:Stroke / Q000401:mortality / Q000523:psychology / Q000628:therapy*