18: Experienced colleagues decisions

Prof Mark Barber

Decision

• No BP intervention
• Treat with alteplase 0.9mg/kg
• No thrombectomy

Thrombolyse (if patient and family wish) but not transfer for thrombectomy.

Rationale

We do see these cases from time to time. She is reaching the end of her life but is currently independent. She would not have been recruited to any of the lysis or thrombectomy trials. Given her underlying problems and life expectancy I would not offer transfer to another hospital for thrombectomy. However, there is a chance that thrombolysis might allow a little more time with reasonable quality of life. A go at thrombolysis might be reasonable, as might a more palliative approach, depending on what the family feel.

Dr Tracey Baird

Decision

• No BP intervention
• No lysis
• No thrombectomy

Rationale

I think treatment decisions here should really be based on patient wishes. Her lung cancer is in itself prothrombotic, decisions on treatment for her stroke may be influenced by the prognosis of her cancer and plan for treatment (curative or palliative). The patient may already have an advanced care directive which could influence decisions.

Dr Anthony Pereira

Decision

• No BP intervention is needed
• Request CT
• No lysis
• No referral for thrombectomy

Rationale

This person has significantly poor health. The malignant disease is also probably a contributory factor for stroke. I would be inclined to treat conservatively here and would want to know more details about their quality of life and whether they had an advanced directive.

In general. at the outset, I would be inclined to request only a CT brain to exclude metastasis.

Dr Shelagh Coutts

Decision

• No BP intervention
• No lysis
• No thrombectomy

Rationale

I would try and get a better idea of prognosis from the metastatic cancer. Lung cancer with liver metastasis likely will not have long life expectancy. Presuming that the prognosis is not great then I would not offer thrombolysis or thrombectomy. This is a judgement call based on prognosis and a discussion with the family. I would have concerns that thrombolysis would lead to hemorrhage into her metastatic disease.

Dr William Whiteley

Decision

• No BP intervention
• Treat with alteplase 0.9mg/kg
• Refer for thrombectomy

Rationale

So here the decision depends on the perceived prognosis from the patient, family and a quick review of the oncology records.

Now many cancers, even metastatic, can have reasonable survival and the field is moving so quickly I do like to check before assuming a metastatic cancer is bound to be fatal in a few weeks or months.

However, if, as seems likely, this woman is close to death from her cancer, I would have a careful conversation with her family. If she was exhausted by her illness, and had expressed the view that the end was near, I would make arrangements for palliative care rather than aim for intervention. If she was wanted to survive (for example to see a grandchild etc..), or had not taken in the cancer diagnosis, then it would be reasonable to intervene.