Ethical and Clinical Considerations at the Intersection of Functional Neuroimaging and Disorders of Consciousness

2016 ◽  
Vol 25 (4) ◽  
pp. 613-622 ◽  
Author(s):  
ADRIAN C. BYRAM ◽  
GRACE LEE ◽  
ADRIAN M. OWEN ◽  
URS RIBARY ◽  
A. JON STOESSL ◽  
...  
Keyword(s):  
Functional Neuroimaging ◽  
Brain Activity ◽  
Basic Research ◽  
Legal Issues ◽  
Disorders Of Consciousness ◽  
Strategic Development ◽  
Brain Injured ◽  
Ethical And Legal Issues ◽  
Clinical Considerations ◽  
Injured Patients

Abstract:Recent neuroimaging research on disorders of consciousness provides direct evidence of covert consciousness otherwise not detected clinically in a subset of severely brain-injured patients. These findings have motivated strategic development of binary communication paradigms, from which researchers interpret voluntary modulations in brain activity to glean information about patients’ residual cognitive functions and emotions. The discovery of such responsiveness raises ethical and legal issues concerning the exercise of autonomy and capacity for decisionmaking on matters such as healthcare, involvement in research, and end of life. These advances have generated demands for access to the technology against a complex background of continued scientific advancement, questions about just allocation of healthcare resources, and unresolved legal issues. Interviews with professionals whose work is relevant to patients with disorders of consciousness reveal priorities concerning further basic research, legal and policy issues, and clinical considerations.

scholarly journals Perturbations in dynamical models of whole-brain activity dissociate between the level and stability of consciousness

2021 ◽  
Vol 17 (7) ◽  
pp. e1009139
Author(s):  
Yonatan Sanz Perl ◽  
Carla Pallavicini ◽  
Ignacio Pérez Ipiña ◽  
Athena Demertzi ◽  
Vincent Bonhomme ◽  
...  
Keyword(s):  
Computational Models ◽  
Brain Activity ◽  
Relevant Information ◽  
Complete Characterization ◽  
Brain State ◽  
Whole Brain ◽  
Brain Injured ◽  
Level Of Consciousness ◽  
The Stability ◽  
Injured Patients

Consciousness transiently fades away during deep sleep, more stably under anesthesia, and sometimes permanently due to brain injury. The development of an index to quantify the level of consciousness across these different states is regarded as a key problem both in basic and clinical neuroscience. We argue that this problem is ill-defined since such an index would not exhaust all the relevant information about a given state of consciousness. While the level of consciousness can be taken to describe the actual brain state, a complete characterization should also include its potential behavior against external perturbations. We developed and analyzed whole-brain computational models to show that the stability of conscious states provides information complementary to their similarity to conscious wakefulness. Our work leads to a novel methodological framework to sort out different brain states by their stability and reversibility, and illustrates its usefulness to dissociate between physiological (sleep), pathological (brain-injured patients), and pharmacologically-induced (anesthesia) loss of consciousness.

When thoughts become action: An fMRI paradigm to study volitional brain activity in non-communicative brain injured patients

NeuroImage ◽  
2007 ◽  
Vol 36 (3) ◽  
pp. 979-992 ◽  
Author(s):  
M. Boly ◽  
M.R. Coleman ◽  
M.H. Davis ◽  
A. Hampshire ◽  
D. Bor ◽  
...  
Keyword(s):  
Brain Activity ◽  
Brain Injured ◽  
Injured Patients

scholarly journals Perturbations in dynamical models of whole-brain activity dissociate between the level and stability of consciousness

2020 ◽  
Author(s):  
Yonatan Sanz Perl ◽  
Carla Pallavicini ◽  
Ignacio Pérez Ipiña ◽  
Athena Demertzi ◽  
Vincent Bonhomme ◽  
...  
Keyword(s):  
Computational Models ◽  
Brain Activity ◽  
Relevant Information ◽  
Complete Characterization ◽  
Brain State ◽  
Whole Brain ◽  
Brain Injured ◽  
Level Of Consciousness ◽  
The Stability ◽  
Injured Patients

AbstractConsciousness transiently fades away during deep sleep, more stably under anesthesia, and sometimes permanently due to brain injury. The development of an index to quantify the level of consciousness across these different states is regarded as a key problem both in basic and clinical neuroscience. We argue that this problem is ill-defined since such an index would not exhaust all the relevant information about a given state of consciousness. While the level of consciousness can be taken to describe the actual brain state, a complete characterization should also include its potential behavior against external perturbations. We developed and analyzed whole-brain computational models to show that the stability of conscious states provides information complementary to their similarity to conscious wakefulness. Our work leads to a novel methodological framework to sort out different brain states by their stability and reversibility, and illustrates its usefulness to dissociate between physiological (sleep), pathological (brain-injured patients), and pharmacologically-induced (anesthesia) loss of consciousness.

From Awareness to Prognosis: Ethical Implications of Uncovering Hidden Awareness in Behaviorally Nonresponsive Patients

2019 ◽  
Vol 28 (04) ◽  
pp. 616-631 ◽  
Author(s):  
MACKENZIE GRAHAM ◽  
EUGENE WALLACE ◽  
COLIN DOHERTY ◽  
ALISON MCCANN ◽  
LORINA NACI
Keyword(s):  
Prognostic Value ◽  
Functional Neuroimaging ◽  
Prognostic Indicators ◽  
Severe Brain Injury ◽  
Ethical Implications ◽  
Highly Sensitive ◽  
Brain Injured ◽  
Life Sustaining Treatment ◽  
Injured Patients

Abstract:Long-term patient outcomes after severe brain injury are highly variable, and reliable prognostic indicators are urgently needed to guide treatment decisions. Functional neuroimaging is a highly sensitive method of uncovering covert cognition and awareness in patients with prolonged disorders of consciousness, and there has been increased interest in using it as a research tool in acutely brain injured patients. When covert awareness is detected in a research context, this may impact surrogate decisionmaking—including decisions about life-sustaining treatment—even though the prognostic value of covert consciousness is currently unknown. This paper provides guidance to clinicians and families in incorporating individual research results of unknown prognostic value into surrogate decisionmaking, focusing on three potential issues: (1) Surrogate decisionmakers may misinterpret results; (2) Results may create false hope about the prospects of recovery; (3) There may be disagreement about the meaningfulness or relevance of results, and appropriateness of continued care.

scholarly journals Ethical, palliative, and policy considerations in disorders of consciousness

Neurology ◽  
2018 ◽  
Vol 91 (10) ◽  
pp. 471-475 ◽  
Author(s):  
Joseph J. Fins ◽  
James L. Bernat
Keyword(s):  
Systems Of Care ◽  
Vegetative State ◽  
High Standard ◽  
Disorders Of Consciousness ◽  
Medical Decision ◽  
Engaged Scholarship ◽  
Brain Injured ◽  
Low Probability ◽  
Injured Patients ◽  
American Academy Of Neurology

This essay complements the scientific and practice scope of the American Academy of Neurology Guideline on Disorders of Consciousness by providing a discussion of the ethical, palliative, and policy aspects of the management of this group of patients. We endorse the renaming of “permanent” vegetative state to “chronic” vegetative state given the increased frequency of reports of late improvements but suggest that further refinement of this class of patients is necessary to distinguish late recoveries from patients who were misdiagnosed or in cognitive-motor dissociation. Additional nosologic clarity and prognostic refinement is necessary to preclude overestimation of low probability events. We argue that the new descriptor “unaware wakefulness syndrome” is no clearer than “vegetative state” in expressing the mismatch between apparent behavioral unawareness when patients have covert consciousness or cognitive motor dissociation. We advocate routine universal pain precautions as an important element of neuropalliative care for these patients given the risk of covert consciousness. In medical decision-making, we endorse the use of advance directives and the importance of clear and understandable communication with surrogates. We show the value of incorporating a learning health care system so as to promote therapeutic innovation. We support the Guideline's high standard for rehabilitation for these patients but note that those systems of care are neither widely available nor affordable. Finally, we applaud the Guideline authors for this outstanding exemplar of engaged scholarship in the service of a frequently neglected group of brain-injured patients.

Specific Computerized Attention Training in Stroke and Traumatic Brain-Injured Patients

2003 ◽  
Vol 14 (4) ◽  
pp. 283-292 ◽  
Author(s):  
W. Sturm ◽  
B. Fimm ◽  
A. Cantagallo ◽  
N. Cremel ◽  
P. North ◽  
...  
Keyword(s):  
Divided Attention ◽  
Single Case ◽  
Baseline Period ◽  
Specific Training ◽  
Attention Task ◽  
Baseline Phase ◽  
Computerized Training ◽  
Brain Injured ◽  
Divided Attention Task ◽  
Injured Patients

Abstract: In a multicenter European approach, the efficacy of the AIXTENT computerized training programs for intensity aspects (alertness and vigilance) and selectivity aspects (selective and divided attention) of attention was studied in 33 patients with brain damage of vascular and traumatic etiology. Each patient received training in one of two most impaired of the four attention domains. Control tests were performed by means of a standardized computerized attention test battery (TAP) comprising tests for the four attention functions. Assessment was carried out at the beginning and at the end of a four week baseline period and after the training period of 14 one-hour sessions. At the end of the baseline phase, there was only slight but significant improvement for the most complex attention function, divided attention (number of omissions). After the training, there were significant specific training effects for both intensity aspects (alertness and vigilance) and also for the number of omissions in the divided attention task. The application of inferential single case procedures revealed a high number of significant improvements in individual cases after specific training of alertness and vigilance problems. On the other hand, a non specific training addressing selectivity aspects of attention lead either to improvement or deterioration of alertness and vigilance performance. The results corroborate the findings of former studies with the same training instrument but in patients with different lesion etiologies.

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