Background: Early deaths are common in stroke, and most occur as a result of brain death or withdrawal of care when prognosis for recovery is believed to be poor. Survivors of severe stroke often have a gradual improvement in function but may experience significant disability, all of which may benefit from skilled palliative care. The objective of this study was to determine the rate of withdrawal of care in patients with ischemic stroke (IS) who underwent different treatment plans.
Methods: We determined the frequency of “withdrawal of care” among patients with IS who received thrombolysis only, endovascular treatment only, both thrombolysis and endovascular treatment and neither thrombolysis nor endovascular treatment. We used Nationwide Inpatient Survey data files from 2006 -2011.
Results: The annual rates of “withdrawal of care” increased from 0.9% in 2006 to 5.5% in 2011, p=<0.0001 in IS patients treated with thrombolysis. The annual rates of “withdrawal of care” increased from 2.8% in 2006 to 9.0% in 2011, p=0.0006 in IS patients who underwent endovascular treatment. The annual rates of “withdrawal of care” increased from 2.0% in 2006 to 10.3% in 2011, p=0.0009 in IS patients treated with thrombolysis and endovascular treatment. The annual rates of “withdrawal of care” increased from 0.8% in 2006 to 3.0% in 2011, p=<0.0001 in IS patients who neither received thrombolysis nor underwent endovascular treatment.
Conclusions: We found a considerable increase in rate of withdrawal of care with aggressive treatment, which may be due to disease severity and/or patient/family preference. Prognostic models and clinical experience for severe stroke patients may be biased by frequent withdrawal of care, leading to errors in prognostication with significant consequences including premature withdrawal of care, suboptimal outcomes and higher risk of short-term mortality.