14 Prognostication, Ethics, and Scales

Arturo Montaño and J. Claude Hemphill III

Abstract

A prognosis for outcome from acute stroke will be expected from doctors by most patients and families. In patients with severe stroke, this prognosis, especially related to long-term function and quality of life, may influence decisions regarding aggressiveness of care. Many different clinical grading scales have been developed for acute ischemic stroke, intracerebral hemorrhage, and aneurysmal subarachnoid hemorrhage that can provide a measure of baseline severity and a prediction of outcome. These grading scales are most often developed from populations of patients using mathematical techniques to assess the association of various clinical, demographic, and neuroimaging predictors on outcome. Thus, they are generally not intended to be applied to individual patients for the purpose of precise prognostication. Numerous other factors including prestroke function, medical comorbidities, and trajectory of improvement over time may also provide prognostic information. Thus, prognostication is inherently uncertain, although it can often provide reasonably accurate general information. There is concern over the self-fulfilling prophecy of poor outcome if a patient with a perceived poor prognosis but potential for recovery has care limited or withdrawn early in their hospital course. Intersecting with the use of prognostic information in medical decision-making are ethical principles that guide the process and interactions between medical providers, patients, and their surrogate decision-makers. The principle of patient autonomy over their medical decisions is prioritized. The concept of shared decision-making is emphasized as a method by which patients and providers work together to respect patient values and goals in the often-challenging context of severe stroke.

Key words

clinical grading scale - prognostication - shared decision-making - autonomy - paternalism - self-fulfilling prophecy

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