Acute Medical Therapies for Persons Living with Physical or Cognitive Disability

In acute medical presentations for persons living with preexisting disability, physicians will often face decisions about acute medical therapies with uncertain safety or efficacy in the patient before them, owing to the poor generalizability of most clinical trials to this population. Using the high-stakes, time-pressured scenario of acute ischemic stroke, this chapter identifies key challenges and unanswered questions in this decision-making process, including (1) flaws in the concept and measurement of pre-morbid disability; (2) challenges in informed consent or assent with a persistent absence of evidence in these patients, partly related to ableism and nihilism; (3) issues stemming from dichotomous concepts of treatment efficacy; and (4) deficiencies in health-economic data that hinder arguments about cost-effectiveness. An evidence-based framework is proposed to guide clinicians, clinician-scientists, and policy-makers regarding the use of acute therapies for these patients.