Article
Mortality re-visited – end of life decisions after decompressive hemicraniectomy in patients with ischemic stroke
Die Entscheidung lebensverlängernde Maßnahmen nach Hemikraniektomie bei Schlaganfallpatienten einzustellen – eine Analyse von Mortalität und Entscheidungsfindung
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Authors
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Xenia Hautmann
- Universitätsmedizin Göttingen, Neurosurgery, Göttingen, Deutschland
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Silvia Hernández-Durán
- Universitätsmedizin Göttingen, Neurosurgery, Göttingen, Deutschland
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Christian von der Brelie
- Universitätsmedizin Göttingen, Neurosurgery, Göttingen, Deutschland
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Veit Rohde
- Universitätsmedizin Göttingen, Neurosurgery, Göttingen, Deutschland
| Published: | June 4, 2021 |
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Outline
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Objective: Decompressive hemicraniectomy (DC) in ischemic stroke is often indicated in an emergency setting and decision making is challenging. Postoperatively patients might remain in a critical condition and the clinical course might be complicated. As clinicians, we often arrive at a point where we feel obliged to challenge and re-evaluate the achievable therapeutic goal. In this study, we performed an analysis on the reasons of mortality and the frequency, reasons and content of “end of therapy” / “end of life” (EoL) decisions.
Methods: We retrospectively analyzed the postoperative course of 109 patients who underwent DC for ischemic stroke at our department between January 2011 and March 2019. We checked if an EoL decision was made and which patient-related factors, CT findings and neurological findings played a role in the EoL decision. We furthermore looked at congruency of the EoL with the alleged patients will.
Results: 39 patients (33%) died during their hospital stay. An EoL decision prior to death was documented in 92.3 % (36 patients) of all deaths. The mean duration between DC and an EoL decision was 9.4 days (range 2-29 days). Higher age was associated with a higher rate of EoL decisions (p=0.005). There was no significant association between CT findings (brain edema, midline shift, brain herniation) and EoL decisions. Postoperative hemorrhagic transformation of the infarction led to a significantly longer duration until an EoL decision was made (p=0.025). Postoperative complications (such as wound problems, hematoma formation) and the side of infarction did not correlate with the rate of EoL decisions. Interestingly, EoL decisions were made more often in men (p=0.031). Male sex correlated highly significant with a higher rate of involvement of relatives in decision making (p=0.01). The alleged patient’s will was evaluated in 75% of all cases. 97.2% of all EoL decisions were taken unanimously between physicians, nurses and relatives. An ethics committee was involved in one case.
Conclusion: The rate of EoL decisions after DC in ischemic stroke was suprisingly high. Our study shows that particular clinical or radiological criteria did not contribute to decision making, while the evaluation of the alleged patient’s will, higher age and interdisciplinary decisions play an important role.
