Introduction: Ischemic stroke is a leading cause of disability and mortality worldwide. As acute stroke patients often lose decisional capacity, the acute situation is fraught with complicated and sometimes conflictive decision making between the patients’ relatives and clinicians. We aimed to explore the medico-ethical challenges with regard to three essential elements of acute stroke care: prognosis, decision- making and management of uncertainty.
Methods: Four focus groups were conducted; two in a university hospital and two in a regional hospital. Twenty-one physicians (13 residents and fellows and 8 attending physicians), working in neurology and neuro-rehabilitation, participated. The discussions were audio- recorded and transcribed verbatim. Transcripts were analysed thematically according to Braun and Clarke’s (2006) reflexive thematic analysis guidelines. Two of the four transcripts were double-coded to establish consistency in the coding framework.
Results: We identified multiple reasons for prognostic uncertainty, arising from limitations in the available information and processes. While multiple tools for improving prognostication seem available, these were not commonly used in clinical practice. In decision making, physicians make use of prudential judgement and affective forecasting. In both prognostication and decision making, time plays a crucial role. We found evidence for a major role of cognitive biases, along with strategies for dealing with this uncertainty, communicating with families and in promoting shared decision making.
Conclusion: The results highlight opportunities to improve stroke care through use of prognostic tools and the need to develop communication strategies for discussing uncertainly, goal-concordant care and promoting shared decision making with patients and families.