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Killer Number Three: Stroke

Palliative Care for a Killer

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Updated October 12, 2008

Killer Number Three: Stroke
Photo © Don Farrall/Getty Images
Stroke, is known as a cerebral vascular accident (CVA), is the third-leading cause of death in the United States (following heart disease and cancer. It was responsible for roughly 1 out of every 16 deaths in the United States in 2004 with an approximate total of 253,000 that year. Since stroke is so deadly, it’s essential to have high quality palliative care programs available to meet victims and their loved one's needs.

Types of Stroke and Emergency Treatment

Ischemic stroke happens when there is a narrowing or blockage of a vessel in the brain caused by a thrombosis or embolism. A cerebral thrombosis is the formation of a blood clot within the brain that blocks blood flow. A cerebral embolism occurs when a clot that has formed elsewhere in the body travels to the brain and blocks blood flow.

Ischemic stroke victims that survive the acute attack may be given clot-buster medication, such as tPA; blood thinners, such as heparin; or anti-clotting agents, such as aspirin.

A hemorrhagic stroke happens when a vessel ruptures and bleeds within the brain. This is most commonly caused by an aneurysm, which is a weakening and bulging of an area of the vessel. Trauma and increased pressure in the brain can lead to a hemorrhagic stroke as well.

Hemorrhagic stroke treatment is aimed at controlling intracranial pressure, or pressure within the skull. No blood thinners or anticlotting agents are used since the stroke is caused by bleeding. The goal of treatment is to stop the bleeding and decrease intracranial pressure to minimize damage to the brain. Intravenous medications to lower intracranial pressure and decrease swelling in the brain, surgery to repair ruptured vessels and/or endovascular treatments to block blood flow to the ruptured vessel may be tried.

Stroke Death and Palliative Care

Despite emergency treatments, approximately 1 in 3 stroke victims die as a result. Death may follow a stroke fairly quickly or come some time later. Stroke victims that survive the initial attack may suffer severe physical and mental deficits. Paralysis, difficulty swallowing, incontinence and mechanical ventilation increase the risk of death. A stroke may leave victims in a coma or a persistent vegetative state, making difficult and important decisions necessary.

Palliative care and hospice programs can help these stroke victims and their loved ones make difficult decisions while addressing their physical, emotional and spiritual needs. The focus of palliative care versus hospice is different for these patients. Palliative care is usually done in the hospital setting without any limitations on life expectancy. Palliative care can be started before a terminal diagnosis is made.

Hospice care, however, is only appropriate for stroke victims who likely have six months or less to live and who prefer to die in their home environment. Hospice is an appropriate choice for someone who has decided against life-prolonging treatments, such as tube feedings and mechanical ventilation. Stroke victims with hospice care are usually brought home or admitted in to a nursing care facility for the remainder of their days.

Deciding Where to Die
Deciding to Withhold or Withdraw Life Support
Artificial Nutrition and Hydration at the End of Life

Read more about palliative care for stroke.

Important Stroke Statistics

  • Each year, about 780,000 people have a new or recurrent stroke.
  • Someone in the United States has a stroke about every 40 seconds.
  • Each year, approximately 60,000 more women have a stroke than men.
  • Blacks have a higher incidence of stroke than whites.
  • Approximately 253,000 people died of stroke in 2004.
  • Someone in the United States dies of stroke approximately every 3 to 4 minutes.

Sources:

American Heart Association. Heart Disease and Stroke Statistics — 2008 Update.

Holloway RG, Benesch CG, Burgin S, Zentner JB. Prognosis and Decision Making in Severe Stroke. JAMA. 2005;294:725-733.

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