Early stroke mortality, patient preferences, and the withdrawal of care bias

OBJECTIVE: Early mortality is a potential measure of the quality of care provided to hospitalized stroke patients. Whether in-hospital stroke mortality is reflective of deviations from evidence-based practices or patient/family preferences on life-sustaining measures is unclear. METHODS: All ischemic stroke mortalities at an academic medical center were reviewed to better understand the causes of inpatient stroke mortality. RESULTS: Among 37 deaths or discharges to hospice in 2009, 36 occurred after a patient/family decision to withdraw/withhold potentially life-sustaining interventions. An independent survey of 3 vascular neurologists revealed that some early deaths could have been delayed beyond 30 days if patients or families had agreed to more aggressive measures. From these data, we estimate the magnitude of a "withdrawal of care" bias to be approximately 40% of the observed short-term mortality. CONCLUSIONS: Acute stroke mortality may be more reflective of patient/family preferences than the provision of evidence-based care.