My Internship

Stroke Facts

• The Risk of having a first stroke is nearly twice as high for African Americans as Caucasians
• African Americans have the highest rate of death due to stroke.
• High blood pressure, high cholesterol, smoking, obesity and diabetes are all leading causes of stroke.
• Remember the signs of stroke by acting F.A.S.T.
  • F- Face
    • Facial drooping is one of the first signs of stroke
  • A-Arms
    • Being unable to move one's arms or one side of their body can indicate stroke
  • S- Speech
    • Slurred speech or trouble forming coherent sentences is another indication
  • T-Time
    • If any of the signs above are present it's time to call 911

Disparities in Access to Palliative Care and Advanced Care Planning after Acute Severe Stroke

Abstract

As severe stroke is associated with high mortality, engaging in advanced care planning, including discussing code status, is important for ensuring that patient’s receive medical treatments in alignment with their values and preferences. This study sought to identify racial disparities in advanced care planning for patients suffering severe stroke. A retrospective medical chart review was conducted of ischemic stroke patients with National Institutes of Health Score (NIHSS) of ≥10 from four hospital systems.

Among the 838 patients in this study, 27% had a DNR/DNI order. Patients with higher NIHSS are more likely to have a DNI/DNR order (p-value =0.03). Patients with withdrawal of artificial nutrition as part of a move to comfort measures were also more likely to have a DNR/DNI order (p-value= 0.02). No significant differences between races in advance care planning documentation in the charts were found. Patients with more severe strokes and those who ultimately move to comfort measures only are likely to have DNI or DNR orders in place. The overall number of patients with advance care planning documentation in their charts is very low, indicating that all severe stroke patients need to be engaged in more advance care planning conversations, regardless of race.

Background

Each year, approximately 795,000 Americans suffer stroke and nearly 140,000 patients will die. As the 5^th leading cause of death in the United States, stroke proves to be a great threat especially among the elderly community. With about 87% of these cases being ischemic, the aims of this research prove to be incredibly pertinent in the improvement of stroke patient care (1).

Advanced care planning is a crucial step in the end of life care of all patients especially those impacted by ischemic stroke as decompensation or death may be a likely outcome. Moreover, the risk for stroke continues to increase after a person has already had one. According to the CDC, nearly 1 in 4 stroke patients are those who have already had a previous stroke (1). With these risks in mind, the steps of advance care planning prove to be important to express the patient’s end of life wishes before the patient is unable to express them for his or herself. Documentation ranging from POST orders to DNR/DNI forms to living wills and power of attorney forms help to keep a patient’s values and preferences at the forefront of their treatment. Additionally, palliative care continues to be an important part of end of life care of severe stroke patients. Palliative care consultations help to direct the important choices in patient goals of care. These two aspects of stroke care should be used in all severe stroke cases to help align patient preferences and goals to their treatment.

This study aims to fill the gaps missing in literature on the racial disparities found in the advanced care planning and palliative care of severe ischemic stroke patients. Though some preliminary research has been conducted on racial disparities within stroke care, it has been noted that acknowledgement of these disparities and continued research to understand where these differences arise is key in finding a solution to unequal healthcare (2).

Literature Review

Nearly all literature suggests that those in the older, Caucasian demographic with high NIHSS or comorbidities such as atrial fibrillation, heart failure, and/or diabetes mellitus are far more likely to receive proper stroke care including advanced care planning and palliative care (3-4). It has also been noted women are more likely than men to receive hospice treatment, a common form of palliative care (4). A study conducted on differences in stroke care among age groups found that there were no significant differences in stroke care delivery. This study highlights that though older patients are more likely to participate in advanced care planning and/or palliative care, the access to these options do not vary by age (5).

Race, however, continues to show stark differences in treatment across all studies. With only 24% of black patients possessing an advance directive compared to the 44% of white patients, it can be reasonably concluded that it is far less likely for black stroke patients to participate in advanced care planning (6). Another issue is that although this demographic of patients is failing to receive proper end of life treatment, they are noted to be nearly twice as likely to suffer a severe stroke (1). The severity of their stroke should make them an ideal candidate for palliative care and advanced care planning, however, it is found that they are instead likely to have longer hospital stays and rarely are moved to comfort measures only. This indicates the mistreatment of the black race within the health care system as they are continuing aggressive treatment and long hospital stays without confirming that is what the patient truly desires (7).

The reason for these racial disparities has remained difficult to pinpoint. One issue indicated by several studies is the variation in use of palliative care among different hospitals (8-10). For example, it has been determined that within white-serving hospitals, minorities are less likely to receive palliative care than white patients. However, palliative care is utilized far less for all demographics in minority-serving hospitals (8-9). This suggests an issue within the minority-serving hospital systems that results in the reduction of palliative care, however, the disparities within the white-serving hospitals highlight that the issue does not end here. There are outside social, economic and educational factors that also play a role (9). Within minorities there are differences in attitudes, beliefs, and socioeconomic status, mistrust of the healthcare system, and cultural and language barriers that may increase difficulty in finding access to proper stroke care as well as decrease the willingness to seek it out themselves (8).

Methodology

Through the chart review tool REDCap, clinical characteristics and other patient information will be collected of patients from five surrounding Indianapolis hospitals. I will work as one of many research assistants to help Ω this retrospective chart review. Patients included in the study must be at least 18 years of age, with a primary discharge diagnosis of ischemic stroke, admitted to the hospital between the start of 2016 to the end of 2018, and have an NIHSS of 10 or higher. Upon meeting inclusion criteria, the charts will be reviewed and data collection will begin. Once all patients have been recorded, the data will be analyzed for any possible trends or themes. Specifically, the data will be statistically analyzed to indicate the proportion of patients with palliative care consultations or any form of advanced directives in place. These patients will then be broken down by patient characteristics to indicate what type of patient is more often correlated with receiving palliative care or possessing an advance directive.

Data

My Contributions

As one of the many research assistants on Dr. Comer's team, I have been able to help analyze some of the hundreds of patient charts in her project. By putting in my share of the work, I have helped to bring the number of remaining charts to analyze down with the help of the other women on our team. This contribution of breaking down several patient charts a week into patient characteristics and their goals of care conversations between the patient and medical staff allows for the project to continue to move forward as we approach the project deadline. The work I am doing is actually quite significant to the project as it aids in the data collection for the conclusion of the study. Ultimately, the conclusions of this research will help to determine the efficiency of health care of severe stroke patients and what changes need to be made so that all patients receive the health care they desire and deserve.

What I've Learned About Myself

As a part of a research team, cooperation is obviously very important. We have several large group meetings at our site where we all ask any questions we have developed as we conduct our chart review. We also offer ways to improve our research or clarify any discrepancies. One way I personally have contributed as a team member is by asking questions at these team meeting. Some questions have just clarified things for myself, but I have asked a couple questions that made our team reconsider the way we collect some of our data. Additionally, I have tried to work as a team member with the other new interns by working together to try to figure things out as we went along with our research. We often touched base with one another to make sure we were on the same page in our progress and to double check any uncertainties we ran into.

I have also found some of my own personal strengths through my work as an intern. Though I may have been aware of these skills before, this job site has strengthened them even more. I have found my communication skills have been a great asset as I've worked with my research team. My ability to ask questions and communicate where I am struggling has helped me to improve in my data collection and assures me that I am on the same page as the rest of the team. My organization skills have also been valuable as I have to organize my daily schedule effectively to fit in time for my internship work. It also has helped me in keeping all of my data collection in order. Lastly, I have found that I am flexible to adverse situations. On a small scale, if any issues would arise that I needed to work around I have always found a way. However, this skill of flexibility has been greatly amplified by my ability to work through the COVID-19 pandemic. The inability to speak with my supervisor face to face has proven to be a bit of a challenge, but I have been able to accomplish the same amount of work as before. Despite these unusual circumstances, I have still been able to find a way to work my hardest as an intern.

Me as a Professional

This internship opportunity has allowed me to grow my professional network through interacting with my research team. My supervisor is obviously very involved in the research community. Additionally, members of our research team are involved in many different health science occupations ranging from physical therapy to nephrology. This has been a great opportunity to get my foot in the door with people involved in many different kinds of potential career interests.

Additionally, this opportunity has brought me closer to some of my career goals. I wanted to explore other avenues of career interests aside from my current interest of genetic counseling. As mentioned above, I have been able to connect with people of all different career backgrounds as well as become an integral part of scientific research. This internship has helped open my eyes to all the possibilities that lay ahead, and it has helped me broaden my horizon of future careers.