• Vol. 42 No. 11, 567–574
  • 15 November 2013

Attitudes and Practices on the Consent Process and Decision-making for Intravenous Stroke Thrombolysis: Physicians’ Perspective



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Introduction: Earlier treatment with intravenous stroke thrombolysis improves outcomes and lowers risk of bleeding complications. The decision-making and consent process is one of the rate-limiting steps in the duration between hospital arrival and treatment initiation. We aim to describe the attitudes and practices of neurologists in Singapore on the consent and decision-making processes for stroke thrombolysis.

Materials and Methods: A survey of neurologists and neurologists-in-training in 2 large tertiary public hospitals in Singapore was conducted.

Results: Among 46 respondents, 94% of them considered stroke thrombolysis an emergency treatment and 67% of them indicated there is a need for written informed consent. The majority (87%) knew that from a legal perspective, the doctor should be the decision-maker in an emergency treatment for a mentally incapacitated patient. However, 63% of respondents reported that it is the next-of- kin who usually makes the decision in actual practice. If confronted with a mentally incapacitated stroke patient, 57% of them were willing to be the proxy decision-maker and 13% of them were not. In 3 commonly encountered vignettes when a mentally incapacitated patient was being considered for stroke thrombolysis, there was no clear consensus on the respondents’ practices.

Conclusion: The next-of-kin is usually the decision-maker for stroke thrombolysis in practice for a mentally incapacitated patient despite most doctors considering thrombolysis an emergency treatment. This, together with the lack of consensus and variance in decision-making and consent practice amongst neurologists for stroke thrombolysis, demonstrates the need to develop best practice guidelines to standardise healthcare practices for greater consistency in health service delivery.

Stroke has serious consequences, and is the leading cause of adult disability worldwide1 and the fourth most common cause of mortality in Singapore. Intravenous (IV) stroke thrombolysis with recombinant tissue plasminogen activator (rt-PA) is the only approved acute drug treatment for ischemic stroke. When given within 4.5 hours of stroke onset, IV thrombolysis is proven to improve functional outcome and reduce the likelihood of dependency but it is also associated with an increased risk of bleeding complications including the devastating symptomatic intracerebral hemorrhage (sICH).

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