What should have been the standard of care at the ER for a mid-70 year old female who had a stroke? Patient had greater than 1-year history of chronic atrial fibrillation, managed with Lanoxin daily. Coumandin theraphy discontined 6-months prior to stroke. On the night of the stroke, patient transported to hospital ER in less then 1-hour. Noncontrast cranial CT showed no acute infraction, hemorrhage or subdural hematoma. Patient had history of transit hemispheric ischemia 12-months ealier with complete neurological resolution. Electrocardiogram showed AFib, rate of 64, no acute ischemic changes. Temperature of 96.5, pulse 0f 81, respirations 18, blood pressure 220/135 and came down to 230/109--Labetalol IV brought pressure to 170/90. MRI not performed. The second part of this question deals with medical ethics. The neurologist on the scene asked patient's husband for premission to do an arteriography--in medical terms that husband couldn't understand. Husband asked potential outcome--the neurologist replied "death." There is no explanation of the proceedure or benefit--just death. Husband broke down and couldn't make decision and ask neurologist to decide. Neurologist declined to do arteriography, but documented that patient's husband declined arteriography and intra-arterial urokinase. Does medical ethics require physicians to do what is necessary for the best possible outcome--even if family members can't decide? Does indecision on the husband's part consitutue a no answer? The answer would been yes had the neurologist took the time to explain (in every day language)that the benefit of arteriograph out-weighted the risk.
Thanks for your question. There are several important information "gaps"
in the clinical scenario of your message that makes it very difficult to
answer your questions, such as:
- What were the stroke symptoms; were they improving , worsening, or stable
during the course of the evaluation in the ER?
- Were there any other significant pre-existing medical conditions other
than the chronic Atrial Fibrillation, and transient (?) systemic h
Explaining the risks/benefits of an invasive procedure is an integral part
of the process of obtaining an Informed Consent for the execution of such
a procedure. Although a complete understanding of all medical technicalities
is not necessary to the patient or the family members, the physician has to
be assured that the deciding party DOES understand the implications of the
decision. Unless there is imminent danger to life, the physician cannot
make that decision for the patient or the patient's family.
The intra-arterial thrombolysis has been proven to be of significant benefit
in the outcome of certain types of stroke, but the outcome is by no mean
always successful, thus it is not a procedure that should be done if there
is not an Informed Consent.
I hope this information is helpful.
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