Cerebrovascular Accident

A Cerebrovascular Accident (CVA), commonly known as a stroke, occurs when the blood supply to a part of the brain is interrupted or reduced, depriving brain tissue of oxygen and nutrients. Within minutes, brain cells begin to die. Strokes are a medical emergency and require immediate attention.

• What it is:
  • Ischemic Stroke: The most common type (about 87% of strokes), caused by a clot that blocks a blood vessel supplying the brain. This clot can form in the brain (thrombotic stroke) or travel from another part of the body (embolic stroke).
  • Hemorrhagic Stroke: Occurs when a blood vessel in the brain leaks or ruptures, causing bleeding into the brain tissue or surrounding areas. This is often linked to uncontrolled high blood pressure or aneurysms (weak spots in blood vessels).
  • Transient Ischemic Attack (TIA): Often called a "mini-stroke," it's a temporary period of symptoms similar to those of a stroke. A TIA doesn't cause permanent damage but serves as a warning sign of a future stroke.
• How it affects the brain: The specific effects of a stroke depend on which part of the brain is affected and the extent of the damage. Brain cells deprived of oxygen die, leading to loss of function in the body parts or cognitive abilities controlled by that area of the brain.
• Progression and Symptoms: The immediate aftermath of a stroke can vary widely, from minor, temporary symptoms to severe, permanent disability or death. Recovery is often a long process, with the most significant improvements typically occurring in the first few months. However, for some, the damage is too extensive, leading to a profound decline.
  • Common immediate symptoms (remember F.A.S.T.): 
    • Face drooping: One side of the face droops or is numb.
    • Arm weakness: One arm is weak or numb.
    • Speech difficulty: Slurred speech, difficulty speaking, or understanding speech.
    • Time to call emergency services.
  • Other common symptoms: Sudden confusion, trouble seeing in one or both eyes, sudden trouble walking, dizziness, loss of balance or coordination, sudden severe headache with no known cause.
  • Long-term effects (vary greatly by stroke severity and location): 
    • Motor Impairment: Weakness or paralysis on one side of the body (hemiparesis or hemiplegia), difficulty with balance and coordination, spasticity (muscle stiffness).
    • Speech and Language Problems (Aphasia): Difficulty speaking, understanding, reading, or writing.
    • Swallowing Difficulties (Dysphagia): Leading to choking, coughing, and risk of aspiration pneumonia.
    • Cognitive Impairment: Memory problems, difficulty with attention, judgment, problem-solving, and in severe cases, vascular dementia.
    • Sensory Changes: Numbness, tingling, or altered sensation.
    • Emotional Changes: Depression, anxiety, mood swings.
    • Bladder and Bowel Control Problems: Incontinence.

In cases where a stroke is massive or where the patient has significant pre-existing conditions, the acute phase can lead directly to a rapid decline, making hospice appropriate. For others, a history of multiple strokes leading to severe functional and cognitive deficits signifies end-stage neurological decline.

Hospice care for stroke patients is considered when the stroke has caused severe, irreversible damage leading to a pronounced decline in function and quality of life, and the medical prognosis is six months or less if the disease runs its expected course. This often applies to individuals who do not recover significantly after a massive stroke, or those with a history of multiple CVAs.

Specific indicators for hospice eligibility for individuals with CVA often include:

• Post-Stroke Functional Decline: Patients typically exhibit severe functional impairment, often measured by:
  • Karnofsky Performance Status (KPS) of ≤40% or Palliative Performance Scale (PPS) of ≤40%: Indicating severe disability and requiring extensive assistance with all personal care.
  • Dependence on others for all activities of daily living (ADLs): Inability to dress, bathe, toilet, transfer, or eat independently.
  • Confined to bed or chair.
• Significant Neurological Impairment:
  • Persistent Vegetative State or Coma: For patients who remain in a comatose or persistent vegetative state following the stroke.
  • Severe Cognitive Deficits (Post-Stroke Dementia): Profound inability to communicate meaningfully, recognize family, follow commands, or process information.
  • Dysphagia (Severe Swallowing Dysfunction): Leading to recurrent aspiration pneumonia, inability to take adequate nutrition/hydration by mouth, and often requiring tube feeding (or the decision to forgo it).
• Recurrent or Persistent Complications: The presence of one or more life-threatening complications that, in conjunction with the stroke's severe effects, support the 6-month prognosis. These often occur within the past 12 months:
  • Recurrent Aspiration Pneumonia: The most common cause of death in severe stroke patients, due to swallowing difficulties.
  • Recurrent Urinary Tract Infections (UTIs): Often due to immobility and bladder dysfunction, potentially leading to sepsis.
  • Sepsis: Any severe infection.
  • Multiple Stage 3 or 4 Pressure Ulcers (Bedsores): Due to profound immobility, poor nutrition, and compromised skin integrity.
  • Persistent Fevers: Especially those of infectious origin, despite antibiotic treatment.
  • Other significant uncontrolled comorbidities (e.g., end-stage heart failure, COPD, renal failure, advanced cancer) that compound the stroke's effects and further limit prognosis.
• Nutritional Decline: Significant weight loss (e.g., 10% weight loss in the previous 6 months) or low serum albumin levels, often due to dysphagia or inability to self-feed. This may occur despite attempts at nutritional support.
   

Hospice care for stroke patients is entirely focused on palliative care, which means providing comfort, managing distressing symptoms, and supporting the patient and their family through the advanced stage of their illness. The interdisciplinary hospice team addresses the patient's physical, emotional, and spiritual needs.

Here's how hospice manages CVA:

• Symptom Control (Primary Focus): Hospice teams are highly skilled at managing the diverse and often severe symptoms associated with end-stage stroke: 
  • Dysphagia (Swallowing Difficulty): This is a critical area. Hospice nurses and aides provide meticulous assistance with oral feeding, ensuring safe positioning and appropriate food textures (e.g., pureed, thickened liquids) to minimize the risk of aspiration. The focus is on comfort feeding – allowing the patient to enjoy what they can safely, rather than striving for nutritional completeness if it causes distress. Decisions about tube feeding are made with the patient/family, centered on comfort.
  • Dyspnea (Shortness of Breath): Often due to aspiration pneumonia or weakened respiratory muscles. Oxygen therapy is used to improve breathing comfort, and medications (like low-dose opioids) can effectively alleviate the sensation of breathlessness.
  • Pain and Spasticity: Stroke can cause various pains (e.g., central post-stroke pain, musculoskeletal pain from immobility, spasticity). Medications are used to manage pain and muscle spasms, and gentle positioning or range-of-motion exercises help reduce discomfort.
  • Incontinence: Bladder and bowel incontinence are managed with regular toileting, absorbent products, and meticulous skin care to prevent breakdown.
  • Pressure Ulcers (Bedsores): Due to immobility, vigorous skin care, regular repositioning, and specialized mattresses are implemented to prevent and treat skin breakdown.
  • Cognitive and Communication Impairment: The team uses strategies to promote comfort and reduce agitation, such as maintaining a calm environment, using consistent routines, and employing non-verbal communication techniques (e.g., gentle touch, music therapy).
  • Seizures: If present, seizures are managed with anti-epileptic medications to ensure patient comfort and safety.
• Medication Management: Hospice nurses manage all medications, optimizing them for comfort and symptom control. They simplify regimens as appropriate, monitor for side effects, and ensure medications are available. A "comfort kit" of emergency medications is often provided at home to manage acute symptom flares.
• Personal Care Assistance: Hospice aides provide hands-on assistance with all activities of daily living (bathing, dressing, grooming, oral hygiene, changing positions), maintaining the patient's dignity and cleanliness.
• Medical Equipment and Supplies: Hospice provides necessary medical equipment (e.g., hospital beds, wheelchairs, commodes, oxygen concentrators, suction machines) and supplies (e.g., incontinence products, wound care dressings) to ensure comfort and safety in the patient's home.
• Caregiver Education and Support: 
  • Training: Hospice staff educate family caregivers on safe techniques for transfers, feeding, repositioning, and managing symptoms.
  • Respite Care: Short-term inpatient stays or in-home aide support provide crucial breaks for family caregivers, who often face significant physical and emotional demands.
  • Emotional and Psychosocial Support: Social workers and counselors provide emotional support, address grief (including anticipatory grief), anxiety, and depression for both the patient and family.
  • Spiritual Care: Chaplains or spiritual counselors offer support consistent with the patient's and family's beliefs.
• 24/7 Availability: Hospice teams typically provide on-call support 24/7, meaning a nurse is always available by phone to answer questions or make a home visit if symptoms worsen unexpectedly, helping to prevent unnecessary emergency room visits and hospitalizations.

By providing comprehensive, compassionate, and holistic care, hospice helps individuals in the advanced stages of stroke and their families navigate this challenging time with the greatest possible comfort, dignity, and support.