[Withdrawing and withholding treatments in acute severe stroke patients in the elderly]

Stroke can produce irreversible brain damage of massive proportion leading to severe disability and poor quality of life. When prognosis is very poor, "do-not-resuscitate (DNR) orders" and "withhold- or withdrawal-of-treatment (WHDT)" may be discussed. Precise estimates of withhold and withdrawal of treatment are not available, but studies have shown that DNR orders are relatively frequent in acute stroke (up to 30% of all patients). DNR orders are closely associated with age, comorbidities, and severity of neurological deficit. The main explicit criteria for WHDT is the risk of "unacceptable" disability, which raises many ethical questions. Evaluation of neurological outcome is highly uncertain and difficult and does not always reflect quality of life. Decisions for life sustaining therapies in severe stroke are always difficult and often based on subjective and uncertain criteria. We have to improve prognosis estimation and our understanding of patient's preferences to promote patient centered care. Ethical approach may guide these complex decisions.