Not all older adults want emergency stroke drug: study

NEW YORK (Reuters Health) - About one-quarter of older adults would not want to receive clot-busting medication for a stroke if they arrived at the hospital unable to make the decision themselves, a new survey found.

The medication, tissue plasminogen activator, or tPA, typically does not save a patient’s life following a stroke. But people who receive tPA or similar drugs tend to have better mental functioning after a stroke and are more likely to be able to live independently, according to Dr. Winston Chiong.

Chiong led the new study at the University of California, San Francisco.

“There’s been a controversy within not just neurology but a number of the disciplines about how to manage this really difficult ethical situation . . . when patients are unable to speak for themselves,” he told Reuters Health.

“They might be unable to speak because of a stroke, or be unable to communicate, or in some cases they might not be aware of the fact that they’ve been debilitated by the stroke.”

In recent years, both the American Academy of Neurology and the American Heart Association/American Stroke Association have released statements supporting the use of tPA for stroke patients who are unable to consent, and when a family member is not present.

The treatment remains underutilized, Chiong said, with less than 5 percent of stroke patients receiving clot-busting medication.

One reason is that tPA is time-sensitive and guidelines say it should only be given to patients who have had a stroke within the past few hours. The medication comes with a risk of bleeding, including bleeding in the brain, so after too long a delay the potential benefits may no longer outweigh the risks.

“If the medication is given early, say within the first three or four and a half hours, it doesn’t increase the risk of death. But there may be some patients who are harmed by the medication,” Chiong said.

“That’s been the main cause for reluctance on the part of many physicians to use this medicine, particularly when the patient can’t engage in a conversation about the risks and benefits.”

To see how older adults feel about potentially receiving tPA after a stroke, he and his colleagues analyzed data from a nationally-representative online survey of 1,100 people ages 50 and older. Half of participants where asked about their wishes in a hypothetical case of cardiac arrest and the other half in a case of stroke.

Twenty-four percent of participants asked about stroke said they would not want to receive tPA or similar medications if they arrived at the hospital after having a stroke, according to the findings published Tuesday in the Journal of the American Medical Association.

The other participants were asked if they would want to be given CPR after a sudden cardiac arrest. A similar proportion said they would not want treatment.

It’s generally accepted that doctors and paramedics can ethically give CPR to a person whose heart has stopped and who cannot consent. So the researchers wanted to compare how potential patients saw both situations.

“For us, this highlights the fact that these situations . . . are really difficult,” Chiong said. “It’s really about this dilemma that many physicians find themselves in of treating patients when we don’t know what their preferences are.”

Dr. Edward C. Jauch led the team that put together the American Heart Association/American Stroke Association guidelines that addressed consent issues for stroke patients.

“I don’t think anybody is advocating for absence of discussion or presumption of consent,” Jauch, head of emergency medicine at the Medical University of South Carolina in Charleston, told Reuters Health.

“What we’re trying to do is to strike a balance because of the need for being very, very quick but also trying to do as much of an informed decision on the patient’s part as possible.”

He pointed out that stroke patients often see being left severely disabled and reliant upon their loved ones as worse than dying, and doctors should take that into consideration when making treatment decisions for patients who can’t make their own.

That might mean treating a patient with a severe stroke with tPA even when it seems risky to do so.

The survey results show that doctors can provide care that is consistent with most people’s wishes by giving tPA and related medications to eligible stroke patients, Chiong said. But it’s still better to know what the individual patient would have wanted.

Because of that, he said the study emphasizes the importance of speaking with family, friends and doctors about treatment wishes before anything goes wrong, and writing those wishes down in advance directives. It’s also an opportunity to reinforce the importance of getting patients to a hospital in time for medications like tPA to be effective.

“It’s most important that people are aware that treatments exist and that if somebody experiences or witnesses a suspected stroke, they should call 911 and that patient should be taken to the hospital by ambulance,” he said.

SOURCE: Journal of the American Medical Association, online April 22, 2014.