Abstract W P294: Balancing Autonomy and Beneficence in Acute Stroke Therapy: Neurologist Attitudes Toward Delaying Thrombolysis in Order to Obtain Informed Consent

Background: In clinical practice, when no consent provider is immediately available to authorize start of thrombolytic stroke therapy, acute stroke physicians face a fundamental conflict between the ethical principles of autonomy (respect for persons) and beneficence (maximizing benefit). Delaying therapy to reach a consent provider maximizes autonomy but reduces benefit. Physician attitudes toward resolving this conflict have not previously been delineated. Methods: A 6 item internet-based survey was administered to US academic stroke neurologists. Respondents were asked to indicate how much time (minutes), patients (number who fail to benefit due to delay), and brain (neurons lost due to delay) they would spend trying to reach consent provider for an aphasic acute stroke patient before proceeding with treatment under the doctrine of presumed consent. Results: Survey responses were received from 103 of 332 academic stroke neurologists. All respondents were engaged in stroke clinical care, with cerebrovascular disease accounting for more than half of practice time in over 70%. Career duration was substantial, with over 72% having been in practice for more than 5 years. In the time tradeoff framework, respondents indicated they would spend a median of 1.75 minutes (interquartile range, IQR, 0 - 10.0 minutes) trying to contact a consent provider before proceeding with thrombolysis. In the patient tradeoff framework, they would accept a median of 0 (IQR 0-0) per 1000 treated patients failing to benefit from therapy before proceeding. In the brain tradeoff scenario, they would accept a median of 0 (IQR 0-1) neurons lost before proceeding. Converting all choices to time, respondents indicated they would trade off shorter times in the patient framework (0 minutes) and the neuron framework (0 minutes) than in the time framework (1.75 minutes). Conclusion: Vascular neurologists indicate they emphasize beneficence over autonomy in deciding when to forego further attempts to reach consent providers to proceed with thrombolytic therapy under the doctrine of presumed consent. Their preference for rapid intervention is magnified when decisions are framed in person failure to benefit and neuron loss, compared with simple chronologic time.