Question: You are called to a retirement home for an 85 y/o female for a possible CVA. On arrival you are met by a Nurse Practioner who stated patient is having a stroke. Nurse Practioner also states that patient (who is a retired RN) has talked to her family doctor who agrees with patient's decision of not wanting to go to stroke centre or stroke protocol done. Patient has history of heart. Assessment reveals patient alert, orientated x 3 and meets stroke protocol. Patient wants to be transported to the local hospital for assessment. Does this patient or any patient have the right to refuse transport to a stroke centre?

 What an interesting and fortunately rare event. Most patients are not aware of the specifics of stroke management: alternate destination of transport to a stroke centre and the specific role of thrombolytics. To have a patient who is so aware of the literature as to make a decision to not wish to be transported to a stroke centre would have to be a rare event.

The bottom line is that if you feel the patient has the capacity make their own decisions and has the ability to understand the risks and benefits associated with refusing transport to a stroke centre (where patients have better outcomes not only from the use of thrombolytics but also gain other benefits from specialized stroke care and rehabilitation), then the patient can refuse.

One should also be cautious that alternate destinations may lead this patient to be transported to a facility which may not have the diagnostic equipment required to delineate the underlying etiology of this patient's condition.

Specifically, the closest hospital may not have a CT scanner, and the patient may be suffering from a different condition other than a CVA. It is quite possible that the closest ED physicican may ultimately request a secondary transport of this patient to a CT capable hospital: not an efficient use of resources if this could have occurred initially. Regardless, once transported to a Stroke Centre, patients can always decline the administration of a thrombolytic yet still gain from the specialized stroke care. This is another benefit of the Stroke Strategy.

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