- 70-yr old man previously fit and well
- Recently retired company director, chairman several charities
- Lives with wife, plays golf regularly
- Felt unwell after coming home for lunch after playing golf. Sudden-onset left arm and leg weakness, speech difficulty
- Presents to the emergency department 2 hours post onset
- On examination – left total anterior circulation syndrome with dense weakness and completely aphasic (cannot communicate at all)
- CTB – dense left middle cerebral artery, no other changes
- He may benefit from thrombolysis – you need to discuss with family
Key points to convey:
- He is very unwell and might die
- Exact prognosis uncertain
- Treatment with thrombolysis may help him or cause harm
- The quicker we do thrombolysis, the more likely it is to be effective – and so there is some urgency in making decisions
- Recovery might be protracted
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Video notes
1:00 The clinician here is aiming to convey the seriousness of the stroke but at the same time wants the focus of the conversation to move on to thrombolysis as quickly as possible. Time is brain.
1:54 Note the emphasis on that it MAY help.
2:26 Emphasise the risks of thrombolysis treatment. The uncertainty of outcome. However, the clinician knows Thrombolysis is indicated and she is keen to treat within the time limit for this treatment.
4:01 The focus of this conversation is on thrombolysis and not about future potential life saving interventions such as cardio pulmonary resuscitation. At this stage Mr Smith would remain for CPR. But included in the conversation is a discussion that even if he is given Thrombolysis he may not necessarily improve.
In summary, reflect on whether you think the conversation was too short or too long. In this situation there is some urgency in decision-making and so conversations need to be focused and brief, yet sensitive and effective. It is sometimes difficult to convey that Thrombolysis might not work, because the purpose of the discussion is to get agreement from the wife to proceed with treatment
- The challenge is to discuss the risks and benefits of thrombolysis in a rapid way and needs to communicate risks and benefits quickly. ‘Time is brain’ when delivering Thrombolysis, but this has to be balanced against the need for the conversation with not rushing for the relative to process information.
- Speak clearly and slowly – checking important information including time of onset. Eye contact is maintained. Although the doctor’s manner might seem serious and business-like, this does help convey the potential seriousness of the situation,
Reflection point
Do you think the conversation was too short or too long? In this situation there is some urgency in decision-making and so conversations need to be focused and brief, yet sensitive and effective.
Page last reviewed: 16 Jan 2023
