Disorders of Consciousness in Clinical Practice

Conscious State ◽

Term Care ◽

Ethical Implications ◽

Decision Making Capacity ◽

Minimally Conscious ◽

Trajectory Of Care

“Disorders of Consciousness in Clinical Practice” considers the ethical, legal, and policy considerations of working with patients and families with severe brain injury. Topics include professional obligations to patients with disorders of consciousness and the ethical implications of coma, brain death and the vegetative and minimally conscious state as well as their diagnostic classification based on behavioral and neuroimaging assessment. The normative challenge of covert consciousness is considered. Clinical, ethical and communication strategies for working with patients with impaired decision-making capacity and their families and surrogates are presented along a typical trajectory of care from initial presentation, intensive care, and discharge to rehabilitation and/or long-term care. End-of-life care, neuropalliation, and bereavement are also discussed as are ancillary care obligations to this marginalized and vulnerable population. Broader policy needs such as access to care is discussed in the context of civil and disability rights.

Judicial oversight of life-ending withdrawal of assisted nutrition and hydration in disorders of consciousness in the United Kingdom: A matter of life and death

Medico-Legal Journal ◽

10.1177/0025817217702289 ◽

2017 ◽

Vol 85 (3) ◽

pp. 148-154 ◽

Cited By ~ 6

Author(s):

Mohamed Y Rady ◽

Joseph L. Verheijde

Keyword(s):

Vegetative State ◽

Conscious State ◽

Disabled Persons ◽

Best Interests ◽

Life And Death ◽

Decision Making Capacity ◽

Nutrition And Hydration ◽

Mr Justice Baker delivered the Oxford Shrieval Lecture ‘A Matter of Life and Death’ on 11 October 2016. The lecture created public controversies about who can authorise withdrawal of assisted nutrition and hydration (ANH) in disorders of consciousness (DOC). The law requires court permission in ‘best interests’ decisions before ANH withdrawal only in permanent vegetative state and minimally conscious state. Some clinicians favour abandoning the need for court approval on the basis that clinicians are already empowered to withdraw ANH in other common conditions of DOC (e.g. coma, neurological disorders, etc.) based on their best interests assessment without court oversight. We set out a rationale in support of court oversight of best interests decisions in ANH withdrawal intended to end life in any person with DOC (who will lack relevant decision-making capacity). This ensures the safety of the general public and the protection of vulnerable disabled persons in society.

Disorders of Consciousness: Terminology and Prognosis

Ethics & Medics ◽

10.5840/em2020451221 ◽

2020 ◽

Vol 45 (12) ◽

pp. 1-2

Author(s):

Gerald J. Nora ◽

Keyword(s):

Conscious State ◽

Right To Die ◽

Positive Outcomes ◽

Recent Advances ◽

Patients with disorders of consciousness have been at the heart of some of the most heated debates on so-called right-to-die cases such as the Terri Schiavo case. People with DOCs occupy a spectrum of disorders from coma to the minimally conscious state. Recent advances in neuroscience have led to insights on the mechanism of these disorders as well as to the revelation that some patients might have a greater degree of awareness than previously believed. These scientific developments have paralleled long-term clinical follow-ups, which have also shown more positive outcomes than expected.

Longitudinal assessments highlight long-term behavioural recovery in disorders of consciousness

Brain Communications ◽

10.1093/braincomms/fcz017 ◽

2019 ◽

Vol 1 (1) ◽

Cited By ~ 6

Author(s):

Corinne A Bareham ◽

Judith Allanson ◽

Neil Roberts ◽

Peter J A Hutchinson ◽

John D Pickard ◽

...

Keyword(s):

Traumatic Injury ◽

Conscious State ◽

Initial Diagnosis ◽

Cross Sectional ◽

Recovery Trajectory ◽

Minimally Conscious ◽

Current Guidelines

Abstract Accurate diagnosis and prognosis of disorders of consciousness is complicated by the variability amongst patients’ trajectories. However, the majority of research and scientific knowledge in this field is based on cross-sectional studies. The translational gap in applying this knowledge to inform clinical management can only be bridged by research that systematically examines follow-up. In this study, we present findings from a novel longitudinal study of the long-term recovery trajectory of 39 patients, repeatedly assessed using the Coma Recovery Scale-Revised once every 3 months for 2 years, generating 185 assessments. Despite the expected inter-patient variability, there was a statistically significant improvement in behaviour over time. Further, improvements began approximately 22 months after injury. Individual variation in the trajectory of recovery was influenced by initial diagnosis. Patients with an initial diagnosis of unresponsive wakefulness state, who progressed to the minimally conscious state, did so at a median of 485 days following onset—later than 12-month period after which current guidelines propose permanence. Although current guidelines are based on the expectation that patients with traumatic brain injury show potential for recovery over longer periods than those with non-traumatic injury, we did not observe any differences between trajectories in these two subgroups. However, age was a significant predictor, with younger patients showing more promising recovery. Also, progressive increases in arousal contributed exponentially to improvements in behavioural awareness, especially in minimally conscious patients. These findings highlight the importance of indexing arousal when measuring awareness, and the potential for interventions to regulate arousal to aid long-term behavioural recovery in disorders of consciousness.

Affirming the right to care, preserving the right to die: Disorders of consciousness and neuroethics after Schiavo

Palliative & Supportive Care ◽

10.1017/s1478951506060238 ◽

2006 ◽

Vol 4 (2) ◽

pp. 169-178 ◽

Cited By ~ 42

Author(s):

JOSEPH J. FINS

Keyword(s):

Brain Injury ◽

Ethical Issues ◽

Vegetative State ◽

Conscious State ◽

Right To Die ◽

Ethical Implications ◽

The Right ◽

In this article, I attempt to untangle some of the cultural, philosophical, and ethical currents that informed the Schiavo case. My objective is to better apprehend what the Schiavo case means for end-of-life care in general and to assert that our discourse about the ethical issues attendant to brain injury will be impoverished if we limit our discussions about disorders of consciousness solely to the vegetative state. If we ignore emerging developments in neuroscience that are helping to elucidate the nature of these disorders and fail to broaden the conversation about brain injury, beyond the unmitigated futility of the permanent vegetative state, we will imperil others who might improve and be helped. Through such efforts we can help mitigate the tragedy of the Schiavo case and overcome the rhetoric that marked the national discourse in March 2005. Once the complexity of disorders of consciousness is appreciated, rhetorical statements about a right to die or a right to life are exposed as being incompatible with the challenge of providing care to such patients. This is especially true as neuroscience brings greater diagnostic refinement to their assessment and management, a topic addressed in this article, which specifically focuses on the clinical and ethical implications of the recently described minimally conscious state. Instead of staking out ideological positions that do not meet the needs of patients or families, we should strive to bothpreserve the right to diefor those who are beyond hopewhile affirming the right to careto those who might benefit from coming advances in neuroscience. If we can achieve that delicate balance, we will be able to transcend the partisan debate that shrouded the life and death of Theresa Marie Schiavo and begin to articulate apalliative neuroethics of carefor those touched by severe brain injury and disorders of consciousness.

Treating Traumatic Brain Injuries with Electroceuticals: Implications for the Neuroanatomy of Consciousness

NeuroSci ◽

10.3390/neurosci2030018 ◽

2021 ◽

Vol 2 (3) ◽

pp. 254-265

Author(s):

Jihad Aburas ◽

Areej Aziz ◽

Maryam Butt ◽

Angela Leschinsky ◽

Marsha L. Pierce

Keyword(s):

Brain Stimulation ◽

Brain Injuries ◽

Vegetative State ◽

Conscious State ◽

Permanent Disability ◽

United States Food ◽

Control And Prevention ◽

According to the Centers for Disease Control and Prevention (CDC), traumatic brain injury (TBI) is the leading cause of loss of consciousness, long-term disability, and death in children and young adults (age 1 to 44). Currently, there are no United States Food and Drug Administration (FDA) approved pharmacological treatments for post-TBI regeneration and recovery, particularly related to permanent disability and level of consciousness. In some cases, long-term disorders of consciousness (DoC) exist, including the vegetative state/unresponsive wakefulness syndrome (VS/UWS) characterized by the exhibition of reflexive behaviors only or a minimally conscious state (MCS) with few purposeful movements and reflexive behaviors. Electroceuticals, including non-invasive brain stimulation (NIBS), vagus nerve stimulation (VNS), and deep brain stimulation (DBS) have proved efficacious in some patients with TBI and DoC. In this review, we examine how electroceuticals have improved our understanding of the neuroanatomy of consciousness. However, the level of improvements in general arousal or basic bodily and visual pursuit that constitute clinically meaningful recovery on the Coma Recovery Scale-Revised (CRS-R) remain undefined. Nevertheless, these advancements demonstrate the importance of the vagal nerve, thalamus, reticular activating system, and cortico-striatal-thalamic-cortical loop in the process of consciousness recovery.

Evaluation of structural variations in the pituitary gland, hormonal status and laboratory markers of the central nervous system functioning in patients with chronic disorders of consciousness

Journal of obstetrics and women s diseases ◽

10.17816/jowd77930 ◽

2021 ◽

Vol 70 (5) ◽

pp. 23-36

Author(s):

Ekaterina A. Kondratyeva ◽

Alina O. Ivanova ◽

Maria I. Yarmolinskaya ◽

Elena G. Potyomkina ◽

Natalya V. Dryagina ◽

...

Keyword(s):

Cerebrospinal Fluid ◽

Blood Serum ◽

Conscious State ◽

Chronic Disorders Of Consciousness

Unresponsive Wakefulness Syndrome ◽

Level Of Consciousness ◽

Chronic Disorders ◽

Minimally Conscious ◽

BACKGROUND: Consciousness is the state of being awake and aware of oneself and the environment. The disorders of consciousness result from pathologies that impair awareness. The development of effective comprehensive personalized interventions contributing to the recovery of consciousness in patients with chronic disorders of consciousness is one of the most pressing and challenging tasks in modern rehabilitation. AIM: The aim of this study was to understand structural problems of the pituitary gland, blood levels of gonadotropins and melatonin as well as brain damage markers in the blood and cerebrospinal fluid in patients with chronic disorders of consciousness and to analyze the levels of the above markers among different groups of patients depending on the level of impaired consciousness. MATERIALS AND METHODS: We examined 61 chronic disorders of consciousness patients and identified three groups depending on the level of consciousness including 24 patients with unresponsive wakefulness syndrome, 24 patients with a minus minimally conscious state, and 13 patients with minimally conscious state plus. We performed magnetic resonance imaging of chiasmatic-sellar region and determined blood serum levels of follicle-stimulating and luteinizing hormones and melatonin, as well as urinary level of 6-sulfatoxymelatonin and the content of brain derived neurotrophic factor (BDNF), apoptosis antigen (APO-1), FasL, glutamate, and S100 protein in the blood serum and cerebrospinal fluid. RESULTS: The patients were examined in the age ranging from 15 to 61 years old. Patient groups were homogeneous by the level of consciousness in terms of age and duration of chronic disorders of consciousness by the time of examination. The patients did not differ in the pituitary volume regardless of the level of consciousness. No significant differences were found between the groups with different levels of consciousness when studying the levels of melatonin in the blood serum and its metabolite in the urine. A peak in melatonin secretion was detected at 3 a.m. in 54.5 % of the patients, which can be considered as a favorable prognostic marker for further recovery of consciousness. Hypogonadotropic ovarian failure was found in 34 % of the patients, with normogonadotropic ovarian failure in the remaining patients. Serum APO-1 and BDNF levels were significantly higher in patients with minimally conscious state relative to those with unresponsive wakefulness syndrome. Significantly lower levels of glutamate in the cerebrospinal fluid were detected in women with unresponsive wakefulness syndrome compared to patients with minimally conscious state. CONCLUSIONS: Further in-depth examination and accumulation of data on patients with chronic disorders of consciousness may provide an opportunity to identify highly informative markers for predicting outcomes and to develop new effective approaches to rehabilitation of consciousness in this category of patients.

Practice guideline update recommendations summary: Disorders of consciousness

Neurology ◽

10.1212/wnl.0000000000005926 ◽

2018 ◽

Vol 91 (10) ◽

pp. 450-460 ◽

Cited By ~ 90

Author(s):

Joseph T. Giacino ◽

Douglas I. Katz ◽

Nicholas D. Schiff ◽

John Whyte ◽

Eric J. Ashman ◽

...

Keyword(s):

Vegetative State ◽

Persistent Vegetative State ◽

Conscious State ◽

Case Definition ◽

Family Counseling ◽

Delphi Consensus ◽

Post Injury ◽

Term Care

ObjectiveTo update the 1995 American Academy of Neurology (AAN) practice parameter on persistent vegetative state and the 2002 case definition on minimally conscious state (MCS) and provide care recommendations for patients with prolonged disorders of consciousness (DoC).MethodsRecommendations were based on systematic review evidence, related evidence, care principles, and inferences using a modified Delphi consensus process according to the AAN 2011 process manual, as amended.RecommendationsClinicians should identify and treat confounding conditions, optimize arousal, and perform serial standardized assessments to improve diagnostic accuracy in adults and children with prolonged DoC (Level B). Clinicians should counsel families that for adults, MCS (vs vegetative state [VS]/unresponsive wakefulness syndrome [UWS]) and traumatic (vs nontraumatic) etiology are associated with more favorable outcomes (Level B). When prognosis is poor, long-term care must be discussed (Level A), acknowledging that prognosis is not universally poor (Level B). Structural MRI, SPECT, and the Coma Recovery Scale–Revised can assist prognostication in adults (Level B); no tests are shown to improve prognostic accuracy in children. Pain always should be assessed and treated (Level B) and evidence supporting treatment approaches discussed (Level B). Clinicians should prescribe amantadine (100–200 mg bid) for adults with traumatic VS/UWS or MCS (4–16 weeks post injury) to hasten functional recovery and reduce disability early in recovery (Level B). Family counseling concerning children should acknowledge that natural history of recovery, prognosis, and treatment are not established (Level B). Recent evidence indicates that the term chronic VS/UWS should replace permanent VS, with duration specified (Level B). Additional recommendations are included.

Non-Invasive Rhythmic Musical-Electric Trigeminal Nerve Stimulation Improves Consciousness in Patients with Disorders of Consciousness

10.21203/rs.3.rs-256846/v1 ◽

2021 ◽

Author(s):

Min Wu ◽

Benyan Luo ◽

Yamei Yu ◽

Xiaoxia Li ◽

Jian Gao ◽

...

Keyword(s):

Trigeminal Nerve ◽

Nerve Stimulation ◽

Brain Activity ◽

Conscious State ◽

Non Invasive ◽

Trigeminal Nerve Stimulation ◽

Novel Approach ◽

Abstract Disorders of consciousness (DOC) are often accompanied by aberrant oscillatory neural activity in the thalamus and cerebral cortex. Patient-friendly non-invasive treatments targeting this functional anomaly are still missing. We propose and validate a novel approach that aims to restore DOC patients’ thalamocortical oscillations by combining rhythmic trigeminal-nerve stimulation (TNS) with comodulated musical stimulation. In a cluster-randomized, placebo-controlled, double-blinded, pretest-posttest clinical study, we show that application of this multisensory approach for 40 min on five consecutive days reliably leads to long-lasting improvements in DOC patients’ consciousness (assessed with Coma Recovery Scale-Revised) and oscillatory brain activity at the musical-electric TNS frequency (assessed with electroencephalography and a novel rhythmic auditory-speech paradigm). We found diagnostic improvement in 47% of patients in minimally conscious state and a positive relationship between patients’ behavioral and neural improvements. Based on this evidence we argue that non-invasive musical-electric TNS may serve as an effective patient-friendly DOC treatment and suggest frequency-specific oscillatory neural enhancement as its mode of action.

Covert Cognition in Disorders of Consciousness: A Meta-Analysis

Brain Sciences ◽

10.3390/brainsci10120930 ◽

2020 ◽

Vol 10 (12) ◽

pp. 930

Author(s):

Caroline Schnakers ◽

Michaela Hirsch ◽

Enrique Noé ◽

Roberto Llorens ◽

Nicolas Lejeune ◽

...

Keyword(s):

Observational Studies ◽

Functional Neuroimaging ◽

Vegetative State ◽

Meta Analysis ◽

Conscious State ◽

Demographic Variables ◽

Minimally Conscious ◽

Increase Sample Size

Covert cognition in patients with disorders of consciousness represents a real diagnostic conundrum for clinicians. In this meta-analysis, our main objective was to identify clinical and demographic variables that are more likely to be associated with responding to an active paradigm. Among 2018 citations found on PubMed, 60 observational studies were found relevant. Based on the QUADAS-2, 49 studies were considered. Data from 25 publications were extracted and included in the meta-analysis. Most of these studies used electrophysiology as well as counting tasks or mental imagery. According to our statistical analysis, patients clinically diagnosed as being in a vegetative state and in a minimally conscious state minus (MCS−) show similar likelihood in responding to active paradigm and responders are most likely suffering from a traumatic brain injury. In the future, multi-centric studies should be performed in order to increase sample size, with similar methodologies and include structural and functional neuroimaging in order to identify cerebral markers related to such a challenging diagnosis.

Disorders of Consciousness and Neuro-Palliative Care

10.1093/oxfordhb/9780199974412.013.15 ◽

2015 ◽

Author(s):

Joseph J. Fins ◽

Maria Masters

Keyword(s):

Palliative Care ◽

Brain Injury ◽

Conscious State ◽

Right To Die ◽

Severe Brain Injury ◽

Brain States ◽

The Right ◽

This chapter explains how neuro-palliative care can be provided to patients with severe brain injury. Before arguing that the right to die must be preserved and that the right to care for patients who are minimally conscious must be supported, it defines and reviews brain states that constitute disorders of consciousness along with their differential biology. It then gives an overview of palliative care for patients with severe brain injury and the challenges involved in diagnosing the minimally conscious state. It proceeds by discussing advances in technology, particularly neuroimaging, that may help meet the needs of such patients. It also considers the neuroethics of diagnosis and concludes by suggesting ways to integrate the needs of individuals suffering from disorders of consciousness in both the local and national palliative care infrastructure.