Melanie R. F. Greenway, MD
International Stroke Conference 2021
March 17–19, 2021
Session: Prognostication and Early Withdrawal of Care in Ischemic Stroke and ICH (116)
Moderators: Aneesh Singhal, MD, and James Meschia, MD
Presenters: Gustavo Saposnik, MD, MPH, PhD, FRCPC; H B Van Der Worp, MD; Claire Creutzfeldt, MD; J Claude Hemphill III, MD, MAS; Wendy Ziai, MD, MPH
Moderated by Dr. Aneesh Singhal from Massachusetts General Hospital and Dr. James Meschia from Mayo Clinic, this session on prognostication in ischemic stroke and intracranial hemorrhage was informative, interactive, and diverse. Topics ranged from accurate prognostication to coaching physicians on important care discussions with patients and families. A must-watch session for those who were unable to watch it live, in my opinion.
Dr. Gustavo Saposnik of St. Michael’s Hospital and the University of Toronto started the session by (painfully) reminding us that poker players and meteorologists are much more accurate in predicting outcomes than physicians. With routine feedback, they are able to refine their practice with data less prone to outcome bias. From there, he took us on a tour of the many validated risk scores available, and their limitations, and encouraged the audience to use risk scores to supplement prognostication rather than “eyeballing” the assessment.
In the second session, Dr. H. B. Van Der Worp from UMC Utrecht encouraged us to acknowledge the uncertainties of neurologic prognostication. He brought to light the cultural and religious differences of patients and their families that may inform end-of-life preferences. He emphasized the importance of discussing clear treatment goals and being aware of potential conflicts of interest when discussing care plans with health care surrogates.
Following Dr. Van Der Worp was an excellent talk by Dr. Claire Creutzfeldt from the University of Washington on how to manage prognostic uncertainty in the setting of stroke. She provided practical advice on communication strategies and methods for building relationships with patients and their families. For many of us, knowing what to say when we are uncertain or uncomfortable can be paralyzing, and she provided tools for navigating the grey zone. She recommended we “acknowledge and normalize uncertainty” and do our best to reduce the risk of underutilizing or overutilizing life-sustaining treatments.
The next talk was by Dr. J. Claude Hemphill of the University of California, San Francisco, and San Francisco General Hospital on the socioeconomic impact of prognostication in stroke. He provided real-world statistics on the cost of healthcare in severe stroke and stated, “there is an inevitable intersection between prognostic decision-making, cost of care, and resource allocation.” While many avoid talking about this intersection, he encouraged us to be more open about it. He provided interesting data about the cost and cost-savings of each decision we make with patients, and recommended we acknowledge the costs upfront and discuss what is acceptable at both the individual and societal level.
Finally, Dr. Wendy Ziai from The Johns Hopkins University School of Medicine discussed the evolution of prognostication in hemorrhagic stroke. The appropriateness of do-not-resuscitate orders and withdrawal of life-sustaining treatment have changed over time with prolonged study of patients. She reviewed the 2015 AHA guidelines that state, “Aggressive care early after ICH onset and postponement of new DNAR until at least the second full day of hospitalization is probably recommended” and that DNAR orders should not limit medical or surgical treatment otherwise. She discussed emerging evidence that suggests waiting even longer than 2 days before new DNAR orders may be appropriate. One key message from her talk was based on outcome data from survivors, which she summarized by stating, “As neurologists, we aspire to have good functional outcomes, but patients and some surrogates keep telling us that maybe survival is just as good.”