American Academy of Neurology provides ethical guidance on consent for people with stroke

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The American Academy of Neurology (AAN) has issued a position statement for neurologists on how to navigate consent issues for people who have experienced acute ischaemic stroke. The statement is published in an online issue of Neurology, the medical journal of the AAN, and was developed by the Ethics, Law and Humanities Committee—a joint committee of the AAN, American Neurological Association and Child Neurology Society.

This new position statement from January 2022 replaces the AAN’s 1999 position paper as well as a 2011 policy statement on this topic.

“Stroke treatments that are effective in preserving brain function can only help if administered quickly, sometimes within just a few hours, yet consent for such treatments must often happen when the person who has had a stroke lacks the ability to make decisions and when those who could make decisions for them may be unavailable,” said position statement author Justin A Sattin (University of Wisconsin, Madison, USA). “This position statement provides ethical guidance for neurologists on how to navigate the decision-making process for stroke patients when time is of the essence.”

The AAN position statement says that, when a person with stroke is unable to give consent for treatment, advance healthcare directives may provide guidance on their wishes. However, it says such directives, like living wills, are often overly specific or too vague, addressing terminal conditions, but not debilitating conditions like stroke. Another form of an advance directive that can be used is a power of attorney—a person who serves as a surrogate decision-maker. Next of kin may also be authorised to serve as a surrogate decision-maker.

The position statement explains that a surrogate decision-maker may not be adequately prepared for representing a stroke patient’s wishes. Neurologists may need to guide them, giving priority to a patient’s preferences, if documented, and if not, then determining what the person would want based on their beliefs. When beliefs are unknown, it says decisions should be made based on the person’s best interests.

When a stroke patient needs emergency treatment and has no advance directive or surrogate decision-maker, the position statement says treatments may be provided based on ethical presumptions of consent—what a person would consent to if they could be asked.

“A stroke is a medical emergency, so by providing this ethical guidance, the American Academy of Neurology aims to help neurologists navigate issues concerning treatment consent so they can provide the highest quality patient care as quickly as possible, saving lives and improving patient outcomes,” said Orly Avitzur, president of the AAN.

The position statement states that, when there is a generally accepted treatment like clot-busting drugs, neurologists may proceed with treatment on the presumption of consent, if necessary.

When treatments require more consideration of risks versus benefits, such as for an endovascular procedure to remove a clot, the position statement says the decision on whether to proceed should be informed by how closely a person’s case matches what is recommended in current treatment guidelines.

When there are treatments for which evidence is lacking, the statement advises that neurologists should work with their medical institutions to develop treatment protocols.

Finally, the position statement says regarding stroke research that laws on consent by surrogates vary state to state, but the federal Common Rule—a rule of ethics in research—allows lawful surrogates to provide consent.


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