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February 2021; 11 (1) Research

Appraisal of Health States Worse Than Death in Patients With Acute Stroke

View ORCID ProfileElyse A. Everett, William Everett, Matthew R. Brier, View ORCID ProfilePatrick White
First published May 6, 2020, DOI: https://doi.org/10.1212/CPJ.0000000000000856
Elyse A. Everett
Department of Medicine (EAE, PW) and Department of Neurology (WE, MRB), Washington University in St. Louis, MO.
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  • ORCID record for Elyse A. Everett
William Everett
Department of Medicine (EAE, PW) and Department of Neurology (WE, MRB), Washington University in St. Louis, MO.
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Matthew R. Brier
Department of Medicine (EAE, PW) and Department of Neurology (WE, MRB), Washington University in St. Louis, MO.
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Patrick White
Department of Medicine (EAE, PW) and Department of Neurology (WE, MRB), Washington University in St. Louis, MO.
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Appraisal of Health States Worse Than Death in Patients With Acute Stroke
Elyse A. Everett, William Everett, Matthew R. Brier, Patrick White
Neurol Clin Pract Feb 2021, 11 (1) 43-48; DOI: 10.1212/CPJ.0000000000000856

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Abstract

Objective To identify health states that patients with acute stroke deem worse than death and to explore potential predictors for these ratings.

Methods This was a cross-sectional study involving patients admitted to an urban comprehensive stroke center with acute stroke. Participants were asked to rate 10 possible health states/functional outcomes as better or worse than death using a 5-point Likert scale. Principal component analysis (PCA) was used to reduce clusters of correlated ratings to summary components (factors). These components were then analyzed using linear regression to identify possible predictive variables.

Results Eighty patients participated. The states deemed equal to or worse than death by the majority of participants were relying on a breathing machine (66%) or feeding tube (66%), persistent confusion (62%), inability to communicate with others (58%), and bowel/bladder incontinence (50%). PCA revealed 2 factors of correlated variables: factor 1 composed primarily of relying on a feeding tube or breathing machine, incontinence, chronic pain, and persistent confusion, and factor 2 composed primarily of using a wheelchair, being bedbound, living in a nursing home, and requiring help for activities of daily living. The only significant predictor found was race for factor 1, with black participants finding these states more preferable to death than white participants.

Discussion A substantial number of patients found multiple common outcomes of stroke to be the same as or worse than death. This highlights the importance of realistic discussions about expected functional outcomes with patients and/or their surrogate decision makers when considering goals of care after stroke.

Footnotes

  • Funding information and disclosures are provided at the end of the article. Full disclosure form information provided by the authors is available with the full text of this article at Neurology.org/cp.

  • Editorial, page 3

  • Received November 19, 2019.
  • Accepted February 21, 2020.
  • © 2020 American Academy of Neurology
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The Nerve!: Rapid online correspondence

  • Reader Response: Appraisal of Health States Worse Than Death in Patients With Acute Stroke
    • Larry B. Goldstein, Chair, Department of Neurology, University of Kentucky
    Submitted March 16, 2021
  • Reader response: Appraisal of Health States Worse Than Death in Patients With Acute Stroke
    • Neil E Schwartz, MD PhD, Clinical Professor, Neurology/Stroke, Stanford University, Dept of Neurology & Neurological Sciences
    Submitted February 28, 2021
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