[Withdrawing and withholding treatments in acute severe stroke patients: clinical and ethical issues]

Stroke prognosis remains difficult to determine. It depends on stroke severity, patient's age and his rehabilitation ability. In essence, individual prediction is uncertain. Neurological severity is related to many factors such as low blood pressure or hyperthermia, which are important to consider before prognosticate. Do-not-resuscitate orders are given in up to 30% of acute stroke. More than 50% of them are given upon admission (in the first 24h of stroke). Withdrawing and withholding treatments are usually decided when neurological prognosis is supposed to be "catastrophic". Other factors, such as physician's disability representation or hospital use of aggressive procedures, certain daily routines or organizational constraints, are also probably implied. In France, end-of-life decisions are guided by the law: "loi relative aux droits des malades et à la fin de vie du 22 avril 2005". Palliative approach in severe stroke remains unknown and rarely developed, but is necessary to implement in such situations with high mortality rate. End-of-life decisions in severe stroke have several ethical issues such as the definition of what could be an "unacceptable" disability for the individual and/or the society.