The American Academy of Neurology
(AAN) is issuing a position statement for neurologists on how to
navigate consent issues for people who have experienced acute ischemic
stroke. The statement is published in the January 10, 2022, online issue
the medical journal of the American Academy of Neurology, and was
developed by the Ethics, Law, and Humanities Committee, a joint
committee of the AAN, American Neurological Association and Child
Neurology Society. This position statement replaces the American Academy
of Neurology’s 1999 position paper as well as a 2011 policy statement
on this topic.
Stroke is the fifth leading cause of death in the United States, with
nearly 800,000 strokes occurring each year. In people 65 and older who
survive a stroke, more than half have reduced mobility. Ischemic stroke
is the most common type of stroke, caused by a blockage of blood flow to
“Stroke treatments that are effective in preserving brain function
can only help if administered quickly, sometimes within just a few
hours, yet consent for such treatments must often happen when the person
who has had a stroke lacks the ability to make decisions and when those
who could make decisions for them may be unavailable,” said position
statement author Justin A Sattin MD of the University of Wisconsin in
Madison. “This position statement provides ethical guidance for
neurologists on how to navigate the decision-making process for stroke
patients when time is of the essence.”
The AAN position statement says when a person with stroke is unable
to give consent for treatment, advance health care directives may
provide guidance on their wishes. However, it says such directives, like
living wills, are often overly specific or too vague, addressing
terminal conditions, but not debilitating conditions like stroke.
Another form of an advance directive that can be used is a power of
attorney, a person who serves as a surrogate decision-maker. Next of kin
may also be authorized to serve as a surrogate decision-maker.
The position statement explains that a surrogate decision-maker may
not be adequately prepared for representing a stroke patient’s wishes.
Neurologists may need to guide them, giving priority to a patient’s
preferences, if documented, and if not, then determining what the person
would want based on their beliefs. When beliefs are unknown, it says
decisions should be made based on the person’s best interests.
When a stroke patient needs emergency treatment and has no advance
directive or surrogate decision-maker, the position statement says
treatments may be provided based on ethical presumptions of consent--what
a person would consent to if they could be asked.
“A stroke is a medical emergency, so by providing this ethical
guidance, the American Academy of Neurology aims to help neurologists
navigate issues concerning treatment consent so they can provide the
highest quality patient care as quickly as possible, saving lives and
improving patient outcomes,” said Orly Avitzur MD MBA FAAN, President
of the American Academy of Neurology.
The position statement says when there is a generally accepted
treatment like clot-busting drugs, neurologists may proceed with
treatment on the presumption of consent, if necessary.
When treatments require more consideration of risks versus benefits,
such as for endovascular treatment, a procedure to remove a clot, the
position statement says the decision on whether to proceed should be
informed by how closely a person’s case matches what is recommended in
current treatment guidelines.
When there are treatments for which evidence is lacking, the
statement advises that neurologists should work with their medical
institutions to develop treatment protocols.
Finally, the position statement says for stroke research, laws
regarding consent by surrogates vary state to state, but the federal
Common Rule, a rule of ethics in research, allows lawful surrogates to
Source: News Release
American Academy of Neurology
January 10, 2022