AAN provides options for treating stroke in patients unable to consent

The American Academy of Neurology has issued a position statement for neurologists that outlines ethical guidance on issues related to consent for individuals with acute ischemic stroke.

A joint committee of the AAN, the American Neurological Association and the Child Neurology Society developed the statement, which replaces AAN’s 1999 position paper and a 2011 policy statement related to these issues. Options such as advance health care directive, power of attorney and next of kin are addressed.

“Stroke treatments that are effective in preserving brain function can only help if administered quickly, sometimes within just a few hours, yet consent for such treatments must often happen when the person who has had a stroke lacks the ability to make decisions and when those who could make decisions for them may be unavailable,” position statement author Justin A. Sattin, MD, professor of neurology at the University of Wisconsin School of Medicine and Public Health in Madison, said in an AAN press release. “This position statement provides ethical guidance for neurologists on how to navigate the decision-making process for stroke patients when time is of the essence.”

According to the statement, when those with stroke are unable to consent to treatment, advance health care directives can offer guidance on their desires. However, directives such as living wills can be too specific or vague and may address terminal conditions but not debilitating conditions, including stroke.

Power of attorney and next of kin can represent another advance directive, the surrogate decision maker. Sattin and colleagues noted these decision makers may not have appropriate preparation for representing the wishes of a patient with stroke. Neurologists may have to offer guidance and prioritize a patient’s preferences when they are documented and, if they are not, determine what the patient may desire based on their beliefs. If beliefs remain unknown, the statement advises making decisions based on the patient’s best interests.

If there is no advance directive or surrogate decision maker and a patient with stroke requires emergency treatment, the authors advised providing treatments according to ethical presumptions of consent, or what a patient would consent to if able to respond.

“A stroke is a medical emergency, so by providing this ethical guidance, the American Academy of Neurology aims to help neurologists navigate issues concerning treatment consent so they can provide the highest quality patient care as quickly as possible, saving lives and improving patient outcomes,” Orly Avitzur, MD, MBA, FAAN, president of the AAN, said in the release.

Neurologists may assume presumption of consent and provide treatment, if necessary, when considering a generally accepted treatment, such as clot-busting. However, they should examine how closely a patient’s case aligns with recommendations in current treatment guidelines for procedures needing further consideration of risk vs. benefits, like endovascular treatment. According to the statement, they and their medical institutions should develop treatment protocols for treatments lacking evidence.

Regarding stroke research, consent laws vary by state; however, federal Common Rule allows for provision of consent by lawful surrogates.

Reference:

• AAN. Who gives consent for treatment when a person with stroke cannot? https://www.aan.com/PressRoom/Home/PressRelease/4947. Published Jan. 10, 2022. Accessed Jan. 12, 2022.