Hospice & Palliative Care

End Stage Neurological Disorders – Stroke 中风 (Learning about hospice)

Stroke is the 3rd leading cause of death in the United States, making the need for hospice care for many victims essential.

A stroke takes time to manifest its full effect, and some early symptoms might be transitory. The physician might consider a referral to hospice if the patient remains comatose or has a severely reduced level of consciousness (obtundation) with abnormal muscle contraction (myoclonus) for 3 days or longer.

Patients who survive 4 weeks and regain significant function during that time are more likely to need active rehabilitation than palliative care.

Specific challenges in stroke patients:

  1. Dysphagia
    • Approximately 1 in 3 patients presents with swallowing problems immediately after the onset of a stroke.
      • Patients who do not tolerate solid food and liquids orally should receive nasogastric (NG), nasoduodenal, or PEG tube feedings to maintain hydration and nutrition while recovering from their strokes.
      • NG tube feeding is preferred in the first 2 to 3 weeks after stroke onset, as approximately 50% of all dysphagia patients will recover their ability to swallow within this time.
      • The question of whether a patient with a poor prognosis and extensive brain damage should receive artificial nutrition is a very important one and should be discussed openly with the patient’s family or power of attorney.
  2. Reduced communication
    • aphasias 失语症
    • dysarthrias 构音障碍
    • neuropsychological deficits such as agnostic 失认症, apraxia 失用症, neglect, and reduced visuospatial 视觉空间的 orientation
  3. Incontinence and bowel management
    • Approximately 1/2 of stroke patients have symptoms of incontinence during the initial hospital stay, but only 20% are affected by urinary incontinence and 10% by fecal incontinence 6 months after their initial stroke.
  4. Pain
    • Pain in stroke patients may be directly related to the intracranial damage or to the results of plegia, such as contracture, pressure sores, or arthralgias caused by immobility.
    • Approximately 10% of the patients suffer from central post-stroke pain, which is a neuropathic pain syndrome characterized by unilateral pain and dysesthesia 感觉迟钝 associated with impaired sensation. The pain is thought to be due to a lesion in the spinothalamic tract or the thalamus itself. This pain is typically resistant to opioids.

Hospice referral criteria:

  1. Karnofsky Performance Scale/ Palliative Performance Scale (PPS) equal or less than 40%
  2. inability to maintain hydration and caloric intake with one of the following:
    • Weight loss of > 10% in the last 6 months or > 7.5% in the last 3 months
    • Serum albumin < 2.5
    • current history of pulmonary aspiration not responsive to speech therapy
    • sequential calorie counts documenting inadequate caloric / fluid intake
    • dysphagia severe enough to prevent patient from continuing fluids / foods necessary to sustain life and patient does not receive artificial hydration and nutrition

References:

Corridor (2006). Hospice Quickflips: A Guide for Hospice Clinicians

Yennurajalingam, S., & Bruera, E. (2016). Oxford American Handbook of Hospice and Palliative Medicine and Supportive Care (2nd. Ed.)

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