Neuro-palliative care and disorders of consciousness

2015 ◽  
Author(s):  
Joseph J. Fins ◽  
Barbara Pohl
Keyword(s):  
Palliative Care ◽  
Brain Injury ◽  
Minimally Conscious State ◽  
Conscious State ◽  
Disorders Of Consciousness ◽  
Therapeutic Interventions ◽  
Severe Brain Injury ◽  
Minimally Conscious ◽  
Neuroprosthetic Devices ◽  
Deep Brain

Neuro-palliative care is an important resource for patients and families confronting severe brain injury. Although many clinicians equate brain injury with certain death or futility, survivors have substantial needs that might be met by palliative care expertise. This chapter suggests that the boundaries of palliative medicine include those with severe brain injury, most notably those in the minimally conscious state, and that with this nosological expansion practitioners of palliative care reflect carefully on often nihilistic attitudes directed towards patients with disorders of consciousness. This chapter establishes how to better meet the needs of these patients and their surrogates, reviewing definitional criteria for the vegetative and minimally conscious states, highlighting advances in diagnostic and therapeutic interventions (such as neuroimaging, drugs, and deep brain stimulation) and considering what neuroprosthetic devices tell us of the capacity of patients to experience-and functionally communicate-pain, distress, and suffering.

Disorders of Consciousness and Neuro-Palliative Care

2015 ◽  
Author(s):  
Joseph J. Fins ◽  
Maria Masters
Keyword(s):  
Palliative Care ◽  
Brain Injury ◽  
Minimally Conscious State ◽  
Conscious State ◽  
Disorders Of Consciousness ◽  
Right To Die ◽  
Severe Brain Injury ◽  
Brain States ◽  
The Right ◽  
Minimally Conscious

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.

Whither the “Improvement Standard”? Coverage for Severe Brain Injury after Jimmo v. Sebelius

2016 ◽  
Vol 44 (1) ◽  
pp. 182-193 ◽  
Author(s):  
Joseph J. Fins ◽  
Megan S. Wright ◽  
Claudia Kraft ◽  
Alix Rogers ◽  
Marina B. Romani ◽  
...  
Keyword(s):  
Brain Injury ◽  
Chronic Conditions ◽  
Minimally Conscious State ◽  
The United States ◽  
Conscious State ◽  
District Court ◽  
Court Case ◽  
Advocacy Groups ◽  
Severe Brain Injury ◽  
Minimally Conscious

As improvements in neuroscience have enabled a better understanding of disorders of consciousness as well as methods to treat them, a hurdle that has become all too prevalent is the denial of coverage for treatment and rehabilitation services. In 2011, a settlement emerged from a Vermont District Court case, Jimmo v. Sebelius, which was brought to stop the use of an “improvement standard” that required tangible progress over an identifiable period of time for Medicare coverage of services. While the use of this standard can have deleterious effects on those with many chronic conditions, it is especially burdensome for those in the minimally conscious state (MCS), where improvements are unpredictable and often not manifested through repeatable overt behaviors. Though the focus of this paper is on the challenges of brain injury and the minimally conscious state, which an estimated 100,000 to 200,000 individuals suffer from in the United States, the post-Jimmo arguments presented can and should have a broad impact as envisioned by the plaintiffs who brought the case on behalf of multiple advocacy groups representing patients with a range of chronic care conditions.

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

2006 ◽  
Vol 4 (2) ◽  
pp. 169-178 ◽  
Author(s):  
JOSEPH J. FINS
Keyword(s):  
Brain Injury ◽  
Ethical Issues ◽  
Vegetative State ◽  
Minimally Conscious State ◽  
Conscious State ◽  
Disorders Of Consciousness ◽  
Right To Die ◽  
Ethical Implications ◽  
The Right ◽  
Minimally Conscious

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 Vegetative State or Minimally Conscious State with Bromocriptine in Traumatic Brain Injury: Review of Clinical Cases

2016 ◽  
Vol 97 (10) ◽  
pp. e92
Author(s):  
Rosa Martin-Mourelle ◽  
Sergio Otero-Villaverde ◽  
Carmen Crespo Lopez ◽  
Jorge Cabrera Sarmiento ◽  
Nelson Gaitan Perez ◽  
...  
Keyword(s):  
Traumatic Brain Injury ◽  
Brain Injury ◽  
Vegetative State ◽  
Minimally Conscious State ◽  
Conscious State ◽  
Minimally Conscious ◽  
Clinical Cases

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

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 ◽  
Minimally Conscious State ◽  
Conscious State ◽  
Disorders Of Consciousness ◽  
Unresponsive Wakefulness Syndrome ◽  
Level Of Consciousness ◽  
Chronic Disorders ◽  
Minimally Conscious ◽  
Chronic Disorders Of Consciousness

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.

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

2021 ◽  
Author(s):  
Min Wu ◽  
Benyan Luo ◽  
Yamei Yu ◽  
Xiaoxia Li ◽  
Jian Gao ◽  
...  
Keyword(s):  
Trigeminal Nerve ◽  
Nerve Stimulation ◽  
Brain Activity ◽  
Minimally Conscious State ◽  
Conscious State ◽  
Disorders Of Consciousness ◽  
Non Invasive ◽  
Trigeminal Nerve Stimulation ◽  
Novel Approach ◽  
Minimally Conscious

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.

scholarly journals Covert Cognition in Disorders of Consciousness: A Meta-Analysis

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 ◽  
Minimally Conscious State ◽  
Conscious State ◽  
Demographic Variables ◽  
Disorders Of Consciousness ◽  
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.

scholarly journals Neuroimaging Studies on Disorders of Consciousness: A Meta-Analytic Evaluation

2019 ◽  
Vol 8 (4) ◽  
pp. 516 ◽  
Author(s):  
Manuela Berlingeri ◽  
Francesca Giulia Magnani ◽  
Gerardo Salvato ◽  
Mario Rosanova ◽  
Gabriella Bottini
Keyword(s):  
Minimally Conscious State ◽  
Conscious State ◽  
Disorders Of Consciousness ◽  
Subcortical Region ◽  
Specific Category ◽  
Estimate Method ◽  
Large Heterogeneity ◽  
Methodological Approaches ◽  
Minimally Conscious ◽  
Dorsal Attentional Network

Neuroimaging tools could open a window on residual neurofunctional activity in the absence of detectable behavioural responses in patients with disorders of consciousness (DOC). Nevertheless, the literature on this topic is characterised by a large heterogeneity of paradigms and methodological approaches that can undermine the reproducibility of the results. To explicitly test whether task-related functional magnetic resonance imaging (fMRI) can be used to systematically detect neurofunctional differences between different classes of DOC, and whether these differences are related with a specific category of cognitive tasks (either active or passive), we meta-analyzed 22 neuroimaging studies published between 2005 and 2017 using the Activation Likelihood Estimate method. The results showed that: (1) active and passive tasks rely on well-segregated patterns of activations; (2) both unresponsive wakeful syndrome and patients in minimally conscious state activated a large portion of the dorsal-attentional network; (3) shared activations between patients fell mainly in the passive activation map (7492 voxels), while only 48 voxels fell in a subcortical region of the active-map. Our results suggest that DOCs can be described along a continuum—rather than as separated clinical categories—and characterised by a widespread dysfunction of brain networks rather than by the impairment of a well functionally anatomically defined one.

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