Surveys of Stroke Patients and Their Next of Kin on Their Opinions towards Decision-Making and Consent for Stroke Thrombolysis

<p><b>INTRODUCTION</b>Early initiation of stroke thrombolysis is associated with improved outcomes. Procurement of consent is a key factor in prolonging the door-to-needle duration. This study aimed to determine the attitudes and preferences of stroke patients and their next of kin (NOK) towards decision-making for stroke thrombolysis in Singapore.</p><p><b>MATERIALS AND METHODS</b>We surveyed acute ischaemic stroke patients (n = 171) who presented beyond the 4.5-hour therapeutic window and their NOK (n = 140) using a questionnaire with scenarios on obtaining consent for intravenous thrombolysis.</p><p><b>RESULTS</b>In the patient survey, 83% were agreeable for their NOK to decide on their behalf if mentally incapacitated and 74% were agreeable for the doctor to decide if the NOK was absent. In the NOK survey, the majority (81%) wanted to be consulted before mentally capacitated patients made their decision; 72% and 74%, meanwhile, were willing to decide on behalf of a mentally capacitated and mentally incapacitated patient, respectively. In the scenario where a doctor recommended a mentally incapacitated stroke patient to undergo thrombolysis but the family declined, there was a near equal split in preference to follow the family's or doctor's decision in both the patient and NOK surveys.</p><p><b>CONCLUSION</b>The survey found that in the decision-making process for stroke thrombolysis, there was no clear consensus on the preference for the decision maker of the mentally incapacitated patient. In Singapore, there is a strong influence of the NOK in decision-making for thrombolysis.</p>

The mental capacity act: implications for patients and doctors faced with difficult choices

The Mental Capacity Act (MCA) came into effect in March 2010 but the impact of this groundbreaking legislation on the doctor-patient relationship has not yet been studied in Singapore. It is evident that communication between healthcare professionals, patients and their loved ones has never been so critical. Translating this into practice, healthcare professionals must identify the decision-maker to obtain consent from the correct person. Consent for healthcare and treatment must be obtained from the patient with capacity or the patient's legally appointed proxy decision-maker under a Lasting Power of Attorney (LPA) where the patient lacks capacity. However, the doctor is the decision-maker for patients lacking capacity in matters of life-sustaining treatment or treatment to prevent a serious deterioration of the patient's health. All decisions made on behalf of persons lacking capacity must be made in their best interests. Capacity assessments must be properly conducted and if a patient has the capacity to make the decision then healthcare professionals must take practicable steps to help them make a decision.

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

<p><b>INTRODUCTION</b>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.</p><p><b>MATERIALS AND METHODS</b>A survey of neurologists and neurologists-in-training in 2 large tertiary public hospitals in Singapore was conducted.</p><p><b>RESULTS</b>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.</p><p><b>CONCLUSION</b>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.</p>