Introduction: The consent process for stroke therapies is limited by the hectic nature of the emergency environment, limited understanding by the patient and family, and time-sensitivity of the event. Patients are often unable to consent, placing the burden on surrogates to infer treatment wishes. Given time-based thrombolytic options, understanding true patient preferences is of paramount importance. We have piloted in a single center (UCSD) study the “Coordinating Options for Acute Stroke Therapy” (COAST) Advanced Directive form to assess and document patient treatment preferences prior to the time of acute stroke presentation.
Methods: The COAST initiative was piloted at a large comprehensive stroke center (UCSD), with deployment including electronic medical record (EMR) integration and provider training. COAST has since been initiated at a second comprehensive stroke center (Stanford), with ongoing expansion into the NIH StrokeNet under a central IRB. In collaboration with the AHA, educational materials are being created to supplement the COAST form and improve the process for a potential larger national deployment.
Results: Patients with a history of stroke, or those at high risk, complete COAST prior to hospital discharge or at clinic visits. The EMR has proven crucial to the deployment and tracking of COAST patients. In a plan to disseminate it “COAST to COAST”, participating StrokeNet centers are deploying the initiative, and collecting data for analysis. A preliminary report on the patients who have completed a COAST form, the optimal location for recruitment, and data on recurrent events, will be provided at the International Stroke Conference.
Conclusions: The COAST advanced directive is a much needed innovation which will make stroke care more efficient, optimize patient autonomy, improve healthcare quality, and streamline the ethical management of complex care decisions in acute stroke. The inherent benefit of COAST is in providing patients and their families with more information regarding stroke and its treatment options, allowing them to take a more active role in their care.