Learning objectives
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Introduction
- Stroke is a common cause of death and is often sudden and unexpected
- Caring compassionate end of life care with good communication is paramount
- Approximately 20% of patients die in the first 30 days.
Anticipated outcome after stroke
- 1. A degree of recovery is anticipated and who are very likely to gain benefit from full rehabilitative measures.
- 2. Extent of stroke and/or the irreversible damage is moderate or unclear. Uncertainty as to the patient’s likely survival. Patient may not survive the next 30 days
- 3. Extensive stroke with profound irreversible damage (and/or co-morbidities) such that death in a matter of days is a probable outcome
Clinical Signs increasing risk of Fatal Outcome
- Coma at onset
- Co-existing maligancy or chronic illness
- Haemorrhagic stroke
- Ventricular haemorrhage
- Basilar artery stroke
- Malignant MCA syndrome
- Severe aspiration and weight loss
Investigations
- Avoid unnecessary tests unless likely to aid palliation e.g. a calcium in someone with malignancy.
Differentials
- Consider Non convulsive status as a rare but treatable cause of coma
- Exclude hypoglycaemia
Management
Management is difficult. Patients are fully or semi comatose and unable to discuss their desired care. We are left trying to do "what the patient would have wanted". Enduring power of attorney can help as they can speak for the patient. The main aim is always compassionate and considerate care and avoiding suffering of any sort at any time. We should try not to prolong suffering or dying when it is inevitable. Its important to establish how much family understand and some have little experience of death and dying and need time, others have more experience. Deaths occur 24/7 on the stroke unit and stroke physicians should take on this role in palliation as part of their skillset.
Hydration: Adults in the last days of life should have their hydration status assessed daily, and have a discussion about the risks and benefits of hydration options. Hydration can have potential risks and benefits. A trial of hydration may be done initially and if no benefit seen then stopped. Patients may survive for 7-10 days after cessation of hydration but can be given oral fluids for mouth care for any symptoms. Complaints of thirst are very rare.
Medications: These can enhance care. Manage agitation with Midazolam which may be given as a syringe drive. Midazolam is a sedative and an antiepileptic that may be used in addition to an antipsychotic drug in a very restless patient. Midazolam is also used for myoclonus. Manage distress, pain, dyspnoea with Morphine. Glycopyrronium bromide may also be used to treat excessive respiratory secretions. Levomepromazine also has a useful sedative effect. See Prescribing in palliative care BNF
References
- [1] End of life care following acute stroke – December 2010. NHS Quality Improvement Scotland 2010
- [2] Prescribing in palliative care BNF
- [3] NICE End of life care for adults QS 13
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