Disorders of Consciousness: Is a Dichotomous Legal Approach Justified?

Abstract Advances made in medical care mean that many critically ill patients with an acquired brain injury may survive with a disorder of consciousness. This may be in the form of a vegetative state (VS) or a minimally conscious state (MCS). Medically, there is a growing tendency to view these conditions as occupying the same clinical spectrum rather than be considered as discrete entities. In other words, their difference is now understood as one of degree rather than kind. However, is English law keeping pace with this development in medical knowledge? This article seeks to highlight the duality that exists in the legal decision-making process in England and Wales, and question the justifiability and sustainability of this dichotomous approach in the light of medicine’s current understanding on disorders of consciousness.

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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 ◽

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.

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All things considered: Surrogate decision-making on behalf of patients in the minimally conscious state

Clinical Ethics ◽

10.1177/1477750920927177 ◽

2020 ◽

Vol 15 (3) ◽

pp. 111-119

Author(s):

L Syd M Johnson ◽

Kathy L Cerminara

Keyword(s):

Decision Making ◽

Medical Decision Making ◽

Vegetative State ◽

Minimally Conscious State ◽

Conscious State ◽

Disorders Of Consciousness ◽

Medical Decision ◽

Surrogate Decision Making ◽

Surrogate Decision ◽

Minimally Conscious

The minimally conscious state presents unique ethical, legal, and decision-making challenges because of the combination of diminished awareness, phenomenal experience, and diminished or absent communication. As medical expertise develops and technology advances, it is likely that more and more patients with disorders of consciousness will be recognized as being in the minimally conscious state, with minimal to no ability to participate in medical decision-making. Here we provide guidance useful for surrogates and medical professionals at any medical decision point, not merely for end-of-life decision-making. We first consider the legal landscape: precedent abounds regarding unconscious patients in coma or the vegetative state/Unresponsive Wakefulness Syndrome (VS/UWS), but there is little legal precedent involving patients in the minimally conscious state. Next we consider surrogates’ ethical authority to make medical decisions on behalf of patients with disorders of consciousness. In everyday medical decision-making, surrogates generally encounter few, if any, restrictions so long as they adhere to an idealized hierarchy of decision-making standards designed to honor patient autonomy as much as possible while ceding to the reality of what may or may not be known about a patient’s wishes. We conclude by proposing an ethically informed, practical guide for surrogate decision-making on behalf of patients in the minimally conscious state.

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Prolonged Disorders of Consciousness

Journal of the Korean Neurological Association ◽

10.17340/jkna.2020.1.2 ◽

2020 ◽

Vol 38 (1) ◽

pp. 9-15

Author(s):

Daeyoung Kim

Keyword(s):

Vegetative State ◽

Minimally Conscious State ◽

Conscious State ◽

Disorders Of Consciousness ◽

Assessment Tools ◽

Impaired Consciousness ◽

Transitional State ◽

Impaired Awareness ◽

Minimally Conscious ◽

Recovery Of Consciousness

Prolonged disorders of consciousness comprise a spectrum of impaired consciousness where arousal is preserved with impaired awareness, which last more than 4 weeks. Vegetative state is a prototype of the prolonged disorders of consciousness. A patient in the vegetative state has no signs of awareness. The minimally conscious state is characterized by inconsistent but reproducible signs of awareness and is regarded as a transitional state of recovery of consciousness. Differentiating patients in minimally conscious state from those in vegetative state is still challenging. Utilizing standardized neurobehavioral assessment tools could improve diagnostic accuracy. Recent advances in neuroimaging and electrophysiologic tools may aid the diagnosis and prognostication. Treatment for recovery of consciousness is still limited. More research on the diagnosis and treatment of prolonged disorders of consciousness is needed not only for improved care of patients with prolonged disorders of consciousness but also a greater understanding of human consciousness.

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Zolpidem Action During Prolonged Disorders of Consciousness (Case Report)

General Reanimatology ◽

10.15360/1813-9779-2019-5-44-60 ◽

2019 ◽

Vol 15 (5) ◽

pp. 44-60 ◽

Cited By ~ 1

Author(s):

E. A. Kondratyeva ◽

M. V. Sinkin ◽

E. V. Sharova ◽

S. Laureys ◽

A. N. Kondratyev

Keyword(s):

Vegetative State ◽

Minimally Conscious State ◽

Conscious State ◽

Disorders Of Consciousness ◽

Eeg Monitoring ◽

Unresponsive Wakefulness Syndrome ◽

Favorable Prognosis ◽

Eeg Activation ◽

Minimally Conscious ◽

Electroencephalogram Eeg

The paper describes two patients with prolonged disorders of consciousness (PDC) because of non-traumatic brain injury, in whom a clear neurodynamic response to Zolpidem was observed.In order to illustrate systemic cerebral responses to administration of this drug in LIC patients, an analysis of clinical and electrophysiological changes has been undertaken.It has been shown that the result of Zolpidem applications in patients with prolonged disorders of consciousness (PDC) should be assessed not only by consciousness dynamics, but with the help of electroencephalogram (EEG) monitoring, too. Distinct response to Zolpidem during different periods of recovery in one patients was found.Zolpidem can render various effects in patients in vegetative state/with unresponsive wakefulness syndrome (VS/UWS) and in minimally conscious state (MCS). In one patient, sedation with EEG activation was observed, which was a sign of favorable prognosis. The other patient developed more than once local convulsions after Zolpidem administration followed by contact augmentation on the next day.The mechanism of action, necessary doses of drugs, and markers of forecasting the successful effect of that drug are yet to be further studied.

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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 ◽

Minimally Conscious State ◽

Conscious State ◽

Disabled Persons ◽

Disorders Of Consciousness ◽

Best Interests ◽

Life And Death ◽

Decision Making Capacity ◽

Nutrition And Hydration ◽

Minimally Conscious

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.

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Information processing in severe disorders of consciousness: Vegetative state and minimally conscious state

Clinical Neurophysiology ◽

10.1016/j.clinph.2005.03.028 ◽

2005 ◽

Vol 116 (10) ◽

pp. 2441-2453 ◽

Cited By ~ 213

Author(s):

B. Kotchoubey ◽

S. Lang ◽

G. Mezger ◽

D. Schmalohr ◽

M. Schneck ◽

...

Keyword(s):

Information Processing ◽

Vegetative State ◽

Minimally Conscious State ◽

Conscious State ◽

Disorders Of Consciousness ◽

Minimally Conscious

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Dissecting the coma spectrum using Bayesian classification

10.1101/832824 ◽

2019 ◽

Author(s):

Martin J. Dietz ◽

Bochra Zareini ◽

Risto Näätänen ◽

Morten Overgaard

Keyword(s):

Vegetative State ◽

Minimally Conscious State ◽

Conscious State ◽

Small Sample ◽

Control Group ◽

Disorder Of Consciousness ◽

Clinical Disorder ◽

Electrophysiological Responses ◽

Alternative Hypotheses ◽

Minimally Conscious

AbstractA patient who does not regain full consciousness after coma is typically classified as being in a vegetative state or a minimally conscious state. While the key determinants in this differential diagnosis are inferred uniquely from the observed behaviour of the patient, nothing can, in principle, be known about the patient’s awareness of the external world. Given the subjective nature of current diagnostic practice, the quest for neurophysiological markers that could complement the nosology of the coma spectrum is becoming more and more acute. We here present a method for the classification of patients based on electrophysiological responses using Bayesian model selection. We validate the method in a sample of fourteen patients with a clinical disorder of consciousness (DoC) and a control group of fifteen healthy adults. By formally comparing a set of alternative hypotheses about the nosology of DoC patients, the results of our validation study show that we can disambiguate between alternative models of how patients are classified. Although limited to this small sample of patients, this allowed us to assert that there is no evidence of subgroups when looking at the MMN response in this sample of patients. We believe that the methods presented in this article are an important contribution to testing alternative hypotheses about how patients are grouped at both the group and single-patient level and propose that electrophysiological responses, recorded invasively or non-invasively, may be informative for the nosology of the coma spectrum on a par with behavioural diagnosis.

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Is Period3 Genotype Associated With Sleep and Recovery in Patients With Disorders of Consciousness?

Neurorehabilitation and Neural Repair ◽

10.1177/1545968315604398 ◽

2015 ◽

Vol 30 (5) ◽

pp. 461-469 ◽

Cited By ~ 4

Author(s):

Gloria Bedini ◽

Anna Bersano ◽

Davide Rossi Sebastiano ◽

Davide Sattin ◽

Francesca Ciaraffa ◽

...

Keyword(s):

Slow Wave Sleep ◽

Total Sleep Time ◽

Vegetative State ◽

Minimally Conscious State ◽

Sleep Time ◽

Conscious State ◽

Disorders Of Consciousness ◽

Sleep Quantity ◽

Minimally Conscious ◽

Post Hoc

Background. Sleep evaluation is increasingly being used as prognostic tool in patients with disorders of consciousness, but, surprisingly, the role of Period3 (Per3) gene polymorphism has never been evaluated. Objective. The aim of this study was to investigate the contribution of Per3 genotype on sleep quantity and consciousness recovery level in patients with disorders of consciousness (DOC). Methods. In this observational study, we evaluated 71 patients with DOC classified as vegetative state/unresponsive wakefulness syndrome or minimally conscious state. Demographic and clinical data were collected and a standardised diagnostic workup, including a polysomnographic record, was applied. After informed consent provided by proxy, genomic DNA was obtained and Per3 polymorphism was analysed by polymerase chain reaction to identify 5/5, 4/5, or 4/4 genotype. Results. Per35/5genotype was found in 12.7% of our DOC patients. The median total Coma Recovery Scale–revised score in Per35/5carriers was significantly higher than 4/4 genotype (10, range 5-16 vs 7, range 4-11; post hoc P = .036). Moreover, total sleep time seemed to be higher in 5/5 genotype ( 5/5, 221 minutes, range 88-515 minutes; 4/4, 151.5 minutes, range 36-477 minutes; and 4/5, 188 minutes, range 44-422 minutes). Conclusion. For the first time we have shown a possible association between Per3 polymorphism and consciousness recovery level in DOC patients. Even though the exact molecular mechanism has not been defined, we speculate that its effect is mediated by higher total sleep time and slow wave sleep, which would improve the preservation of main cerebral connections.

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Selegiline in Patients With Disorder of Consciousness: An Open Pilot Study

Canadian Journal of Neurological Sciences / Journal Canadien des Sciences Neurologiques ◽

10.1017/cjn.2018.315 ◽

2018 ◽

Vol 45 (6) ◽

pp. 688-691

Author(s):

Orsola Masotta ◽

Luigi Trojano ◽

Vincenzo Loreto ◽

Pasquale Moretta ◽

Anna Estraneo

Keyword(s):

Vegetative State ◽

Minimally Conscious State ◽

Conscious State ◽

Clinical Effects ◽

Disorder Of Consciousness ◽

Brain Injured ◽

Minimally Conscious ◽

Injured Patients ◽

Open Pilot

AbstractThis open study investigated the clinical effects of 10-week selegiline administration in six patients in vegetative state and in four patients in a minimally conscious state, at least 6 months after onset. Clinical outcome was assessed by Coma Recovery Scale-Revised once a week during selegiline administration and 1 month later. Three patients stopped treatment because of possible side effects. After treatment and at 1 month of follow-up, four patients showed improvements in clinical diagnosis, and three patients showed an increase in arousal level only. Selegiline might represent a relatively safe option to enhance arousal and promote recovery in brain-injured patients with disorders of consciousness.

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Results of a prospective study (CATS) on the effects of thalamic stimulation in minimally conscious and vegetative state patients

Journal of Neurosurgery ◽

10.3171/2015.7.jns15700 ◽

2016 ◽

Vol 125 (4) ◽

pp. 972-981 ◽

Cited By ~ 29

Author(s):

Lorenzo Magrassi ◽

Giorgio Maggioni ◽

Caterina Pistarini ◽

Carol Di Perri ◽

Stefano Bastianello ◽

...

Keyword(s):

Vegetative State ◽

Minimally Conscious State ◽

Conscious State ◽

Cortical Activation ◽

Disorder Of Consciousness ◽

Chronic Stimulation ◽

Thalamic Stimulation ◽

Minimally Conscious ◽

Deep Brain ◽

Stimulation Of

OBJECTIVE Deep brain stimulation of the thalamus was introduced more than 40 years ago with the objective of improving the performance and attention of patients in a vegetative or minimally conscious state. Here, the authors report the results of the Cortical Activation by Thalamic Stimulation (CATS) study, a prospective multiinstitutional study on the effects of bilateral chronic stimulation of the anterior intralaminar thalamic nuclei and adjacent paralaminar regions in patients affected by a disorder of consciousness. METHODS The authors evaluated the clinical and radiological data of 29 patients in a vegetative state (unresponsive wakefulness syndrome) and 11 in a minimally conscious state that lasted for more than 6 months. Of these patients, 5 were selected for bilateral stereotactic implantation of deep brain stimulating electrodes into their thalamus. A definitive consensus for surgery was obtained for 3 of the selected patients. All 3 patients (2 in a vegetative state and 1 in a minimally conscious state) underwent implantation of bilateral thalamic electrodes and submitted to chronic stimulation for a minimum of 18 months and a maximum of 48 months. RESULTS In each case, there was an increase in desynchronization and the power spectrum of electroencephalograms, and improvement in the Coma Recovery Scale–Revised scores was found. Furthermore, the severity of limb spasticity and the number and severity of pathological movements were reduced. However, none of these patients returned to a fully conscious state. CONCLUSIONS Despite the limited number of patients studied, the authors confirmed that bilateral thalamic stimulation can improve the clinical status of patients affected by a disorder of consciousness, even though this stimulation did not induce persistent, clinically evident conscious behavior in the patients. Clinical trial registration no.: NCT01027572 (ClinicalTrials.gov)

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