Psychosocial, Ethical, and Care Coordination Issues
Emotional and cognitive sequelae
Post-stroke depression affects roughly a third of survivors, can appear early or months later, and impairs rehabilitation participation. Screen with a validated tool (PHQ-9 or similar) rather than relying on impression. Pseudobulbar affect - involuntary laughing or crying incongruent with mood - is distinct from depression and is treated differently. Anxiety, apathy, fatigue, sexual dysfunction, and caregiver burden are common and under-recognized. Involve social work, psychology, and support groups early.
Decision-making and capacity
Capacity is decision-specific and assessed at the time of the decision. Thrombolysis consent is often obtained from a surrogate under emergency provisions; document who consented and why. Honor existing advance directives, and where the patient lacks capacity, use a documented surrogate hierarchy. Goals-of-care conversations should be proactive, iterative, and independent of prognosis estimates that may change with treatment.
Transitions and equity
Discharge planning begins on admission: home safety, transportation, medication access and affordability, caregiver training, follow-up scheduling, and rehabilitation setting. Screening for social determinants of health - insurance, housing, language, health literacy - is part of stroke care, not an optional extra. Palliative care is appropriate alongside curative treatment for symptom burden and goals clarification, not only at end of life.
Traps: a patient who seems appropriately sad still needs formal depression screening. Do not equate crying with depression. Do not assume incapacity from aphasia; provide communication supports and assess ability to express a choice.
Rule of thumb: ask every survivor and caregiver about mood, burden, and what matters most to them before discharge.