The American Heart Association (AHA) released a comprehensive scientific statement emphasizing that palliative care should be integrated throughout all stages of stroke treatment, not just end-of-life care. The statement, published in Stroke, provided updated clinical assessment tools, treatment protocols, and hospice referral criteria.
Stroke affects approximately 800,000 people annually in the U.S., with 140,000 deaths. While advances in acute stroke treatment reduced mortality rates, they also increased the survivor population facing long-term challenges.
The statement introduced several clinical assessment tools for physicians, including the SuPPOrTT checklist for identifying palliative care needs, the Critical Care Pain Observation Tool for non-communicative patients, and the HOPE instrument for spiritual care needs assessment.
For treatment, the guidelines outlined specific protocols for central poststroke pain management using antidepressants (tricyclics, SSRIs, SNRIs) and antiseizure medications (lamotrigine, pregabalin, gabapentin). Additional recommendations included physical therapy and NSAIDs for hemiplegic shoulder pain, and stretching exercises, muscle relaxants, and botulinum toxin for spasticity management.
The statement provided specific hospice referral criteria, including limited oral intake without artificial nutrition, complications such as aspiration pneumonia or sepsis, poor prognostic imaging findings, and coma persisting for 3 days with absent verbal response, brainstem reflexes, and withdrawal response to pain.
For end-of-life symptom management, the guidelines addressed pain (affecting 25% to 65% of patients) and dyspnea (16% to 81%) using intermittent opioids and benzodiazepines. Management of respiratory secretions included repositioning and glycopyrrolate/scopolamine patches.
Analysis of discharge patterns revealed that 34%-45% of patients were discharged home without services, 10%-11% with home care services, 30%-42% to inpatient post-acute care facilities, 6% to 8% died in hospital, 2% to 3% went to inpatient hospice, and 1% received home hospice.
The statement identified significant research gaps, noting that in a systematic review of postacute palliative care interventions, only 7 studies met criteria. Limited evidence existed for integrating palliative care into routine stroke care.
Claire J. Creutzfeldt, MD, who chaired the writing committee, highlighted that while most strokes are not immediately life-threatening, they are always life-altering and require high-quality, person-centered care.
The document addressed inequities in care access, noting that Black and Hispanic individuals were consistently less likely to have advance directives compared with White individuals, with Black individuals having 77% lower odds and Hispanic individuals having 70% lower odds of completing advance directives.
Conflict of interest disclosures can be found in the guidelines.
