Article

Stroke can produce irreversible brain damage of massive proportion
leading to severe disability and poor quality of life. Resuscitation and
mechanical ventilation of these patients remain controversial because of the high
mortality and severe disability involved. When prognosis is very
poor, do-not-resuscitate orders (DNR orders) and withhold or withdrawal of
treatment may be discussed. Studies have shown that DNR orders are relatively
frequent in acute stroke: up to 30% of all patients, and 50% of which are given
upon admission. DNR orders are closely associated with severity of the
neurological deficit and age. Precise estimates of withhold and withdrawal of
treatment are not available, but terminal extubations in severe stroke could
contribute to 40,000 to 60,000 acute stage deaths per year. Little is known about
the decision making process and palliative care in these situations. The
neurological prognosis is the main explicit criterion. However, evaluation of
neurological outcome is highly uncertain and difficult, and does not always
reflect quality of life. Several studies have raised the issue of this disability
paradox. Thus, physician estimation of prognosis has a profound impact on
decisions for life sustaining therapies, and may lead to self-fulfilling
prophecies in case of false appreciation of published evidence. Other criteria
could influence the withhold and withdrawal of treatment decision, such as social
conditions and patient values. PERSPECTIVES AND CONCLUSION: Decisions for
life-sustaining therapies in severe stroke are always difficult and often based
on subjective and uncertain criteria. We have to improve prognosis estimation and
our understanding of patient preferences to promote patient-centered care. An
ethical approach may guide these complex decisions.
CI - Copyright (c) 2011 Elsevier Masson SAS. All rights reserved.

Langue : FRANCAIS