Context An increasing number of deaths following severe stroke are due to terminal
extubations. Variation in withdrawal-of-care practices suggests the possibility
of unnecessary prolongation of suffering or of unwanted deaths.
Objectives To review the available evidence on prognosis in mechanically ventilated
stroke patients and to provide an overall framework to optimize decision making
for clinicians, patients, and families.
Data Sources Search of MEDLINE from 1980 through March 2005 for English-language
articles addressing prognosis in mechanically ventilated stroke patients.
From 689 articles identified, we selected 17 for further review. We also identified
factors that influence, and decision-making biases that may result, in overuse
or underuse of life-sustaining therapies, with a particular emphasis on mechanical
Evidence Synthesis Overall mortality among mechanically ventilated stroke patients is high,
with a 30-day death rate approximating 58% (range in literature, 46%-75%).
Although data are limited, among survivors as many as one third may have no
or only slight disability, yet many others have severe disability. One can
further refine prognosis according to knowledge of stroke syndromes, early
patient characteristics, use of clinical prediction rules, and the need for
continuing interventions. Factors influencing preferences for life-sustaining
treatments include the severity and pattern of future clinical deficits, the
probability of these deficits, and the burdens of treatments. Decision-making
biases that may affect withdrawal-of-treatment decisions include erroneous
prognostic estimates, inappropriate methods of communicating evidence, misunderstanding
patient values and expectations, and failing to appreciate the extent to which
patients can physically and psychologically adapt.
Conclusions Although prognosis among mechanically ventilated stroke patients is
generally poor, a minority do survive without severe disability. Prognosis
can be assessed according to clinical presentation and patient characteristics.
There is an urgent need to better understand the marked variation in the care
of these patients and to reliably measure and improve the patient-centeredness
of such decisions.