Stroke and Coma
Stroke and Coma
Patients will be considered to be in the terminal stage of stroke if they meet the following criteria: 1 and 2 should be present; factors from 3 will lend supporting documentation:
- Palliative Performance Scale (PPS) of 40% or less
- Inability to maintain hydration and caloric intake with one of the following:
- • Serum albumin < 2.5 gm/dl.
- • Current history of pulmonary aspiration not responsive to speech language pathology intervention.
- • Sequential calorie counts documenting inadequate caloric / fluid intake.
- • Dysphagia severe enough to prevent the patient from receiving food and fluids necessary to sustain life, in a patient who declines or does not receive artificial nutrition and hydration.
- Weight loss > 10% in the last six months or > 7.5% in the last three months.
- Documentation of diagnostic imaging factors which support poor prognosis after stroke include:
- A) For non-traumatic hemorrhagic stroke
- • Large-volume hemorrhage on CT.
- • Infratentorial: ≥20 ml.
- • Supratentorial: ≥50 ml.
- • Ventricular extension of hemorrhage
- •Surface area of involvement of hemorrhage ≥30% of cerebrum.
- • Midline shift ≥1.5 cm.
- • Obstructive hydrocephalus in patient who declines, or is not a candidate for, ventriculoperitoneal shunt.
- B) For thrombotic / embolic stroke
- Large anterior infarcts with both cortical and subcortical involvement.
- • Large bihemispheric infarcts.
- • Basilar artery occlusion.
- • Bilateral vertebral artery occlusion.
- 1) Comatose patients with any three of the following:
- • Abnormal brain stem response
- • Absent verbal response
- • Absent withdrawal response to pain
- • Serum creatinine >1.5 mg/dl
- 2) Documentation of medical complications, in the context of progressive clinical decline, within the previous 12 months, which supports a terminal prognosis:
- • Aspiration pneumonia
- • Upper urinary tract infection (pyelonephritis)
- • Sepsis
- • Refractory stage 3-4 decubitus ulcers
- • Fever recurrent after antibiotics