Ethical Issues in Stroke Management

A variety of ethical issues may arise in the management of patients with stroke.(1) The adequacy of informed consent may be questioned in the incapacitated patient with acute stroke for whom IV alteplase administration is planned despite the absence of a lawful surrogate decision maker. The decision-making capacity of a patient with a recent dominant hemispheric infarction causing nonfluent aphasia may become an issue when he appears to understand but cannot communicate his treatment preference. Neurologists may be unsure whether to provide medical hydration and nutrition to an elderly patient admitted with a massive intracranial hemorrhage and incipient herniation whose advance directive states that life-sustaining treatment is to be withheld in the event of a hopeless prognosis. A patient with chronic locked-in syndrome from pontine infarction may order that further life-sustaining treatment be withdrawn, but her neurologist may be unsure of the ethical adequacy of her treatment refusal because of communication limitations.