A 78-year-old woman is brought to the emergency department after her neighbor found her slumped over on her front porch bench, unable to speak or walk. The neighbor reports that, 2 hours prior, he had seen the patient walking to her mailbox. He spoke with her for a few minutes, and she seemed normal at that time. The patient lives alone but has an adult daughter in another town. Vital signs are normal. Neurologic examination demonstrates right-sided hemiparesis and aphasia. The patient is a candidate for thrombolysis but does not appear to understand when the risks and benefits of thrombolysis are discussed. The daughter could not be reached by phone on the initial attempt. Which of the following is the most appropriate next step regarding consent for thrombolysis in this patient?

Question

A 78-year-old woman is brought to the emergency department after her neighbor found her slumped over on her front porch bench, unable to speak or walk.  The neighbor reports that, 2 hours prior, he had seen the patient walking to her mailbox.  He spoke with her for a few minutes, and she seemed normal at that time.  The patient lives alone but has an adult daughter in another town.  Vital signs are normal.  Neurologic examination demonstrates right-sided hemiparesis and aphasia.  The patient is a candidate for thrombolysis but does not appear to understand when the risks and benefits of thrombolysis are discussed.  The daughter could not be reached by phone on the initial attempt.  Which of the following is the most appropriate next step regarding consent for thrombolysis in this patient?

Quizplus · Accepted Answer

Explanation: This patient has symptoms of a debilitating stroke and is a candidate for thrombolysis, a therapy endorsed by evidenced-based guidelines for acute ischemic stroke. Thrombolysis greatly decreases poststroke disability, but its efficacy is time-dependent (ie, "time is brain"). Therefore, thrombolysis administration is urgent, so delays in treatment should be minimized. When possible, the risks and benefits of thrombolysis are briefly discussed with the patient to obtain consent for treatment. However, an exception to informed consent includes treatment of life-threatening emergencies (eg, stroke) when there is inadequate time to obtain consent or when the patient's capacity to give informed consent is impaired, as in this patient with receptive aphasia. Because of the circumstances of emergency stroke care and the safety and efficacy of thrombolysis, consent is not required to administer thrombolysis on an emergency basis. Therefore, this patient should receive tissue plasminogen activator without further delay (Choice D). (Choice B) Most states designate the legal surrogate hierarchy as follows: spouse (unless divorced or legally separated), then adult child, parent, and adult sibling. A few states also give authority to a "close friend"; however, this patient's neighbor is not necessarily a close friend, and it is unlikely that he would know the patient's wishes regarding her medical care. More important, consent for treatment with thrombolysis is not required on an emergency basis. (Choice C) Two-physician consent is often obtained when nonemergency medical decisions (eg, end-of-life care) are required and no one can be identified to act on behalf of an incapacitated patient. However, consent for emergency thrombolysis is unnecessary; in addition, finding a second physician and waiting for the second evaluation may also create a significant (and detrimental) delay. (Choice E) When a patient's capacity to provide consent for emergency care is impaired, a rapid and reasonable attempt is typically made to determine the patient's wishes by consulting a living will or locating a legal surrogate. However, withholding thrombolysis for an indefinite length of time (eg, hours) until the consent of a legal surrogate (eg, patient's daughter) can be obtained is inappropriate and unnecessary; delay reduces thrombolysis efficacy and neurologic recovery, and emergency thrombolysis may be given without consent. Educational objective: Consent for thrombolysis in acute ischemic stroke should be obtained from the patient when possible. However, because time to treatment is critical (ie, "time is brain"), thrombolysis can be given on an emergency basis without consent. References: Getting the gist across is enough for informed consent for acute stroke thrombolytics. (http://www.ncbi.nlm.nih.gov/pubmed/31084320)

A 78-Year-Old Woman Is Brought to the Emergency Department After