Goal-Concordant Care in the Era of Advanced Stroke Therapies

Stroke is a leading cause of disability and mortality worldwide. Recent advances in stroke care now enable patients with severe ischemic stroke owing to large vessel occlusion to safely undergo endovascular thrombectomy (EVT) up to 24 hours since their time of last known well, with the goal of improving functional outcomes by recanalization of the occluded vessel and reperfusion of downstream ischemic brain tissue. The objective of this analysis is to highlight clinical and ethical challenges related to ensuring goal-concordant care in this era of unprecedented advances in acute stroke care. Specifically, there is a salient challenge of whether advanced therapies such as EVT may be justifiably considered comfort focused, given their potential to preempt accumulated neurologic disability and suffering at the end of life. Through the lens of a patient case, we discuss key challenges, lessons learned, and suggestions for future care and research endeavors at the intersection of acute stroke care and palliative care principles. Although therapies such as thrombolysis and EVT may be considered aggressive prima facie, their potential to ameliorate additional disability and potential suffering at the end of life prompt close consideration of the proper role of these therapies on a case-by-case basis in the context of comfort-focused care. Modification to the workflow for EVT evaluations may facilitate goal-concordant care and timely resource allocation, especially for cases that involve hospital-to-hospital transfers for advanced stroke care.

Automated summary

Stroke is a major global cause of disability and death, and advances in treatment now allow for endovascular thrombectomy within 24 hours of stroke onset to improve functional outcomes. Ensuring goal-concordant care in the era of acute stroke treatment advancements poses challenges in considering therapies like EVT in the context of comfort-focused care to prevent neurological disability and suffering at the end of life. Modifications to EVT evaluation workflows may facilitate timely resource allocation for cases requiring hospital-to-hospital transfers for advanced stroke care.