Stroke is usually a dramatic event; unlike the progressive neurological deterioration of amyotrophic lateral sclerosis (ALS) or Parkinson's disease, and its outcome is difficult to predict. The sudden onset of stroke may call for urgent interventions to reduce progression or extension of brain damage, including administration of aspirin, thrombolytic drugs and blood pressure reduction, plus supportive care – intravenous (I-V) hydration, investigation of cause, prevention of deep vein thrombosis (DVT), early mobilization and appropriate diet. From that acute presentation approximately one third will die within days, one third will achieve a complete or partial recovery, and one third will not improve, and risk further deterioration and eventual death. That last group will be left with severe brain damage, be at risk of severe disability and major discomforts; it is for them that palliative management is most appropriate.

SUPPORTIVE PHASE

The initial symptoms and discomforts common in stroke will be treated expectantly, looking for improvement and encouraging an emphasis on rehabilitation. Where there is further deterioration, emphasis shifts to the maintenance of comfort. There are common difficulties for these patients requiring careful analysis and specific interventions if quality of life is to be satisfactory.

Palliation issues

Bulbar symptoms, swallowing and communication difficulties

Bulbar symptoms may occur through paralysis of motor speech functions, specific damage to cerebral speech areas and connections, or more complex psychological effects with restlessness and anxiety compromising self-awareness and impairing patient descriptions of discomfort.