To the Editor:

We wish to thank Bianchin et al1 for the interest they have shown in our work and for their supportive comments. As they rightly point out in the emotionally fraught and time-constrained context of a clinical deterioration following acute stroke, family members are often called upon to provide support for the decision to surgically intervene. This can place an enormous psychological burden on relatives who are already distressed due to the impact of the initial illness. In these circumstances, discussions regarding outcome cannot be dichotomized into life or death because this will fail to recognize that surgical decompression will not reverse the effects of what is, by definition, a very extensive stroke. The fundamental issue rests on the acceptability or otherwise of survival with severe disability and dependency.

There is no doubt that many such patients will provide so called “retrospective consent” and this may indeed serve to illustrate that for them life itself may be more important than quality of life. However, we would contend that to interpret this as a variation of the consenting process is problematic.2 Obtaining a positive response when asking a person whether they would agree to an intervention that has enabled them to stay alive, albeit with a considerable alteration in functional status, is certainly a testament to the human will to survive and adapt to adverse and challenging circumstances. However, to use this as a justification for the surgical intervention (especially when the most likely outcome is dependency with significant neuropsychological deficits) would undermine the fundamental tenet of modern medicine that requires informed consent to be provided prior to any form of medical intervention.

Realistically, in the emotionally charged atmosphere of an acute stroke, it would be very difficult to withhold therapy if there was at least some chance of survival with an acceptable level of disability, and the possibility of unacceptable dependency was acknowledged and accepted by those involved in making the decision. Treatment based on such reasoning can be justified even if the eventual outcome seems unacceptable to the injured party because risks and uncertainties are inevitable in all fields of medicine. It could also be argued given the alternative would be not to survive at all, a young person may quite reasonably be given the chance to “risk” survival with an mRS of 4 in the hope that they will either improve to achieve an mRS of 3 or learn to accept a level of disability that they might previously have deemed unacceptable.2

There are also many individuals who feel that life is sacrosanct and worth preserving under any circumstances, and this may be based on certain religious, cultural, or personal values and, as Bianchin et al1 point out, this is particularly true given the diverse cultures around the world. Whilst these views may fall outside what is deemed acceptable to the majority, where possible, these views should be acknowledged and acted upon. For these patients, surgical intervention is entirely reasonable.

There will however be those patients who have previously expressed a view (either previously voiced or documented) that they would not want to survive with severe disability.3 In these circumstances, a surgeon cannot reasonably assume that he would be able to obtain consent for the operation and if he did proceed, he would have to justify acting on their own judgment against a properly considered assessment of the wishes of the patient. It could, of course, be argued that competent individuals do not necessarily predict what they will later find acceptable or unacceptable as a quality of life; however, if a person has previously made this assessment whilst competent, it should be respected and acted upon accordingly.

Withholding surgical intervention is further justified by reviewing the results of the pooled analysis of the 3 European trials in which the most likely outcome following standard medical therapy is either death or survival with an mRS of 3 and thereby some degree of independence.4 For those patients over 60 years of age, the ethical imperative is even more compelling, given the findings of the DESTINY II.5 This clearly demonstrated that most survivors were dependent and over half of them had insufficient neuropsychological function such that they could answer a relatively simple question regarding retrospective consent.6

Overall there is unlikely to be a one-size-fits-all approach to the difficult problem of patient selection especially in the time-constrained circumstances of acute stroke. However, given the evidence available, it is clear that acceptable outcome for a particular individual must be considered as early as possible following diagnosis of stroke, ideally when the patient is relatively stable. This avoids the need for hasty decisions that cannot be mitigated occurring after a catastrophic deterioration where the ethical issues are either sidelined or not really considered at all.

We argue that the “rule of rescue” does not automatically justify a lifesaving procedure, both ethically and legally, just because the procedure can increase a person's chance of immediate survival; when there is a high chance that the person may survive in a functional state, he/she would consider unacceptable when they are competent.7 In summary, we agree with the carefully reasoned comments by Bianchini et al1 and hope to continue to explore some of the many remaining ethical considerations regarding lifesaving but nonrestorative surgical intervention.

Disclosure

The authors have no personal, financial, or institutional interest in any of the drugs, materials, or devices described in this article.

REFERENCES

1.
Bianchin
MM
,
Brondani
R
,
de Almeida
AG
.
Letter: ORACLE Stroke Study: opinion regarding acceptable outcome following decompressive hemicraniectomy for ischemic stroke
.
Neurosurgery
 .
2016
;
79
(
2
):
231
-
236
.
2.
Honeybul
S
,
Gillett
GR
,
Ho
KM
,
Janzen
C
,
Kruger
K
.
Is life worth living? Decompressive craniectomy and the disability paradox
.
J Neurosurg
 .
2016
;
125
(
3
):
775
-
778
.
3.
Honeybul
S
,
Ho
KM
,
Blacker
DW
.
ORACLE Stroke Study: opinion regarding acceptable outcome following decompressive hemicraniectomy for ischemic stroke
.
Neurosurgery
 .
2016
;
79
(
2
):
231
-
236
.
4.
Vahedi
K
,
Hofmeijer
J
,
Juettler
E
et al
DECIMAL, DESTINY, and HAMLET investigators. Early decompressive surgery in malignant infarction of the middle cerebral artery: a pooled analysis of three randomised controlled trials
.
Lancet Neurol
 .
2007
;
6
(
3
):
215
-
222
.
5.
Jüttler
E
,
Unterberg
A
,
Woitzik
J
et al
DESTINY II Investigators. Hemicraniectomy in older patients with extensive middle-cerebral-artery stroke
.
N Engl J Med
 .
2014
;
370
(
12
):
1091
-
1100
.
6.
Honeybul
S
,
Ho
KM
,
Gillett
G
.
Outcome following decompressive hemicraniectomy for malignant cerebral infarction: ethical considerations
.
Stroke
 .
2015
;
46
(
9
):
2695
-
2698
.
7.
Honeybul
S
,
Gillett
GR
,
Ho
KM
,
Lind
CR
.
Neurotrauma and the rule of rescue
.
J Med Ethics
 .
2011
;
37
(
12
):
707
-
710
.