When treating stroke patients, physicians often have to make vital decisions regarding personal treatment plans. Based on the patients’ chances of recovery, the doctors must decide whether therapy should be intensive, comfort-based, or somewhere in between.
Based on the findings of a new survey, which revealed that physicians vary widely in their treatment recommendations, a group of neurologists is now encouraging colleagues to slow down before heading out to the waiting room to discuss treatment recommendations with family members.
In general, quality measures at individual centers often require physicians to document a prognostic score in the chart while treating stroke patients. These prognostic scores are meant to provide a standardized assessment of severity. But the effect of showing doctors these scores has not previously been tested.
For the new study, researchers set out to see whether having a model would change the physicians’ recommendations. They sent out a survey to 742 physicians across the U.S. that included sample cases of two patients with a brain hemorrhage.
The investigators incorporated characteristics they believed would elicit a variety of different responses from the doctors, such as patient age and stroke severity. The responding physicians had to predict the 30-day mortality rate and recommend treatment intensity for each case.
The researchers included prognostic scores for some of the sample patients but not for others.
“We wanted to see if you approach treatment differently if you’re being told the patient’s chance of recovery,” said University of Michigan neurologist Darin Zahuranec, M.D., principal investigator of the physician survey published in Neurology.
“There’s a lot of variability across centers in terms of how these patients are treated. We wanted to see what role, if any, the physicians may play in that variability. The range of predicted mortality was from zero percent to 100 percent in most of the cases. I was surprised to see that level of variability among physicians.”
In general, a doctor will most likely recommend an intensive approach for stroke patients who have a strong chance of recovery, whereas if the patient’s chances of recovery are low, the doctor may recommend a treatment that is more comfort-based. The stakes for these decisions are even higher in cases of brain hemorrhage, a severe type of stroke after which about one-third of patients die within a month.
According to the findings, treatment recommendations varied widely among the responding physicians, with some suggesting comfort measures only and others suggesting full intensive treatment for the exact same patient.
In the most severe case, when the score suggested zero percent chance of recovery, physicians were more likely to recommend comfort measures only. In a mild case, physicians who saw a better chance of recovery were more likely to recommend full intensive treatment with the goal of rehabilitation.
The findings also revealed that neurosurgeons tend to be more optimistic about mortality predictions than neurologists, and physicians who saw the most brain hemorrhage cases were slightly more pessimistic than those who saw fewer cases.
Although the researchers tried to control for physician personality, such as religion or optimism, none of those factors predicted the physicians’ treatment recommendations.
Since brain hemorrhage patients are not usually able to participate in these prognosis discussions, physicians often end up sharing their recommendations with family members, who are eager for the doctor’s insight before making a care decision.
The researchers recommend that doctors pause to remember what strong variability there is even among experts regarding these cases. They ask clinicians to slow down and consider the situation before sharing any prognosis with stroke patients and families, who are already dealing with a high-stress situation.
“Do we really know what we think we know when making these predictions?” Zahuranec said. “My hope for physicians is that we really understand the impact of our prognostic statements.”
Zahuranec suggests that physicians first discuss with the family what a good recovery would entail, and what would be important for that individual patient, and then tailor the predictions and recommendations to those wishes.
“These situations are always very difficult for the family and for the physicians,” Zahuranec said. “One thing that can make things easier is when the family has a clear understanding of what the patient would want.”