Guidelines for determining prognosis: stroke and coma
After stroke, patients who do not die during the acute hospitalization tend to stabilize with supportive care only. Continuous decline in clinical or functional status over time means that the patient's prognosis is poor.
Conversely, steady improvement in the patient's functional or physiologic status may indicate that the patient is not terminally ill. Care should be taken to distinguish true recovery of performance and physiologic function from the improvement in symptoms and subjective well-being that can accompany hospice intervention.
I. During the acute phase immediately following a hemorrhagic or ischemic stroke, any of the following are strong predictors of early mortality:
A. Coma or persistent vegetative state secondary to stroke, beyond three days' duration.
B. In post-anoxic stroke, coma or severe obtundation, accompanied by severe myoclonus, persisting beyond three days past the anoxic event.
C. Comatose patients with any 4 of the following on day 3 of coma had 97% mortality by two months:
C1. Abnormal brain stem response
C2. Absent verbal response
C3. Absent withdrawal response to pain
C4. Serum creatinine >1.5 mg/dl
C5. Age >70
D. Dysphagia severe enough to prevent the patient from receiving food and fluids necessary to sustain life, in a patient who declines, or is not a candidate for, artificial nutrition and hydration.
E. If computed tomographic (CT) or magnetic resonance imaging (MRI) scans are available, certain specific findings may indicate decreased likelihood of survival, or at least poor prognosis for recovery of function even with vigorous rehabilitation efforts, which may influence decisions concerning life support or hospice. It should be borne in mind that clinical variables, not imaging studies, are the primary criteria for hospice referral.
II. Once the patient has entered the chronic phase, the following clinical factors may correlate with poor survival in the setting of severe stroke, and should be documented.
A. Age greater than 70.
B. Poor functional status, as evidenced by Karnofsky score of < 50%.
C. Post-stroke dementia, as evidenced by a FAST score of greater than 7.
D. Poor nutritional status, whether on artificial nutrition or not:
D1. Unintentional progressive weight loss of greater than 10% over past six months.
D2. Serum albumin less than 2.5 gm/dl, may be a helpful prognostic indicator, but should not be used by itself.
E. Medical complications related to debility and progressive clinical decline. It is assumed that these patients are in chronic care situations similar to those with end-stage dementia. Although studies are not available to relate these directly to six-month prognosis in stroke, their presence should be documented.
E1. Aspiration pneumonia.
E2. Upper urinary tract infection (pyelonephritis).
E4. Refractory stage 3-4 decubitus ulcers.
E5. Fever recurrent after antibiotics.
See also: FAST, Karnofsky, Stroke. Cerebrovascular accident
Published by The National Hospice Organization, 1996.
Reference: U.S. Department of Health and Human Services. Assistant Secretary for Planning and Evaluation. Internet. Accessed April 29, 2010. Available at http://aspe.hhs.gov/daltcp/Reports/impquesa.htm#appendixC.