Introduction: Stroke is the 2nd most common cause of death and the leading cause of disability worldwide. Stroke survivors have high rates of comorbid medical conditions; one in 5 stroke survivors will suffer a recurrent stroke within 5 years, and a TIA doubles the risk for heart attack. In the acute stroke setting, patients are frequently unable to participate in their own medical decision making. Therefore, advanced care planning (ACP) should be a fundamental part of post-stroke care.
Methods: We surveyed stroke survivors and stroke physicians in our tertiary care stroke clinic as part of a quality improvement program. All new and follow-up patients were invited to complete a 12 question survey on ACP, including history of relevant discussions and perceived risk of recurrent stroke or disability. Stroke physicians documented demographic data, NIHSS, any acute treatment received, mRS and provided a risk estimate for recurrent stroke or death.
Results: Between March and July 2017, 198 surveys were completed. Median age was 61 years (IQR 50-70), 94 (47.5%) were female, and 61% presented to the stroke clinic for the first time after their stroke. The majority (55%) had an initial NIHSS of 5 or less, and 10% had received IV tPA or thrombectomy during their acute stroke care. At the time of follow-up, median mRS was 1 (IQR 0-2). Almost ¾ (n=145) had had a conversation with a physician about ACP, and 110 (56%) wanted to discuss ACP with their stroke physician. Less than one half (n=88) had advance directives (AD) in place. Patients were significantly more likely to have AD if they were white (53% compared to 24% in all other races, p<0.001) and less disabled (55% for those with mRS 0-1 compared to 31% in those with mRS ≥ 2 (p=0.002). Having discussed their risk of recurrent stroke with a physician was also associated with higher rates of AD (58% vs 37%, p=0.004).
Conclusions: Most patients presenting to stroke clinic do not have advance directives, but a willingness to discuss ACP is common. We identified certain groups who were less likely to have advance care plans. Our findings suggest that the stroke clinic may be an optimal setting for a targeted intervention to increase access to ACP.