- The 70-year old man, David Smith who had an ischaemic stroke (left hemisphere Total Anterior Circulation Stroke) – whom we ‘met’ in the first scenario
- Previously fit
- Had been thrombolysed but no improvement
- Arrives on stroke unit having spent 3 days in admissions ward; family had had brief discussions with medical staff; family feel that different people had given different information
- Dense hemiparesis with aphasia and an ‘unsafe’ swallow
- He’s developed a temperature and sounds ‘chesty’
- Nasogastric feeding not yet commenced due to concerns about his chest
Goals for discussion:
- Establish trust with family and check whether there are other family members who aren’t present and who would want to be involved in discussions
- Explain the present situation clearly, avoid using too many medical terms. In this scenario the effects on the brain, speech, swallowing, breathing etc. Relate this to the symptoms which they can see and if necessary show them the CT brain scan
- Explain that it’s difficult in making predictions about whether acute treatments will help and how much recovery there will be. This might explain the apparent ‘mixed messages’ previously
- Establish what the patient would want if he could communicate, e.g. Has he ever expressed any prior views about living with severe disability that might guide management?
- Explain to family that we would like to involve them in decision-making but they should not feel responsible for the decisions that are ultimately made- making shared decisions is our goal to promote patient centred care
- Discuss views on early treatment decisions such as antibiotics, fluids and tube feeding; with patient preferences being the centre of such discussions
Background:
The Stroke registrar arrives at the stroke ward. The consultant is in a clinic. Mr Smith arrived on the stroke unit last night at 8pm having spent three days in the admissions ward. This is now day 4 of his admission. He had presented with a left middle cerebral artery territory stroke and had been Thrombolysed. Despite early treatment within 2½ hours of onset of symptoms, he still has a dense right hemiparesis, is aphasic and his visual fields could not be tested as he is unable to follow commands.
He was reviewed briefly by the on-call team last night who noted that he was stable medically. The Stroke registrar also reviews him this morning. He’s still ‘nil by mouth’ and is not receiving nasogastric feeding. He’s sounding ‘chesty’, his temperature is up, his oxygen saturations have fallen a little and he can hear some bibasal crackles. The Stroke registrar suspects that he may be developing pneumonia. He is drowsier and his eyes are no longer opening to speech. His family (wife and older daughter) are present, having arrived early in the morning as they sense that he is not so well. His son is not present but has been in regular contact with the rest of the family. The younger daughter is in America. His family are worried about his care and don’t understand why he hasn’t improved with thrombolysis. The admissions team had recommended thrombolysis on the basis that this was his best chance of making an early recovery. They have told the nurse who is on duty that they want to speak to a doctor.
Page last reviewed: 16 Jan 2023
