Disorders of Consciousness and the Use of Neurotechnologies
L. Syd M Johnson, Karen S. Rommelfanger in The Routledge Handbook of Neuroethics, 2017
Disorders of consciousness (DOC) are a group of conditions characterized by impaired verbal and motor responsiveness to diverse stimuli, indicating disturbed consciousness (Bernat, 2006). Almost uniformly, these disorders result from an acute and severe brain injury. In younger patients, this is often a head trauma caused by an accident, while in older patients the causes are more often stroke, brain hemorrhage or hypoxic brain injury due to cardiopulmonary arrest (in which the brain lacks oxygenated blood for several minutes). The acute severe brain injury immediately induces a coma, which is a state of complete unresponsiveness with eyes closed in which even the most painful stimuli cannot elicit any verbal or behavioral responses (Young, 2009). If the patient survives, the clinical situation stabilizes and the brain slowly starts to recover, the patient can transition into an unresponsive wakefulness syndrome (UWS), also called vegetative state. This is indicated by the fact that the patient resumes periods of wakefulness with eyes open, alternating with periods of sleep with eyes closed.
Medicolegal aspects of death
Jason Payne-James, Richard Jones in Simpson's Forensic Medicine, 2019
Disorders of consciousness (DOC) include: coma, vegetative state (VS), and minimally conscious state (MCS). Following severe brain injury, many patients progress through stages of coma, VS and MCS as they emerge into a state of full awareness. However, some will remain in a vegetative or minimally conscious state for the rest of their lives. The diagnosis, management and lifelong (including end-of-life [EOL]) care of adults who have prolonged disorders of consciousness (PDOC), persisting for more than 4 weeks following sudden onset profound acquired brain injury is a sensitive and complex area. In 2013, The Royal College of Physicians published ‘Prolonged Disorders of Consciousness: National Clinical Guidelines, which advise clinical and ethical standards of care for people with PDOC.’ For the purposes of the guidelines, the definitions in Table 3.1 are used to differentiate between these states.
Neurologic Disorders in Documentary Film
Eelco F.M. Wijdicks in Neurocinema, 2014
Most comatose patients and those in a minimally conscious state are cared for in a nursing home, but there are uniquely specialized centers, such as the JFK Medical Center, that admit patients for care and research. Disorders of consciousness, particularly when severe or prolonged, are artificially divided into minimally conscious state and persistent vegetative state, and physicians use several clinical tools to differentiate between the two (Table 5.1). For families, to make that distinction is difficult, and there are always moments when they think they see “more responsiveness.” For physicians, the challenge is to judge these reactions accurately and not to easily dismiss them as “reflexes.” Unfortunately, there are too many instances in which the physician has ignored families’ observations, and when the patient improves there is much consternation and distrust. Prolonged observation by multiple healthcare providers skilled in this work is the only way to ascertain lack of awareness or improvement in responsiveness.
What Justifies the Allocation of Health Care Resources to Patients with Disorders of Consciousness?
Published in AJOB Neuroscience, 2021
Andrew Peterson, Sean Aas, David Wasserman
Disorders of consciousness (DoC) are neurological conditions that are characterized by a global impairment of consciousness for an extended period of time. Two closely studied disorders of consciousness are the vegetative state (VS)—also referred to as the unresponsive-wakefulness syndrome—and the minimally consciousness state (MCS) (Giacino et al. 2014). Patients in the VS display semi-regular sleep-wake cycles but no behavioral evidence of awareness (Jennett and Plum 1972). Patients in the MCS display semi-regular sleep-wake cycles and a range of one or more volitional behaviors, including responses to painful stimuli, object recognition, visual tracking, and command following (Giacino et al. 2002). Incidence rates of the VS and the MCS vary due to heterogeneity in clinical assessment. However, available systematic reviews report rates as high as 6.1 per 100,000 population for the VS (Italy) and 1.5 per 100,000 population for the MCS (Austria) (Pisa et al. 2014; Van Erp et al. 2014). Patients who survive often have complex disabilities and require specialized long-term care.
Late recovery of awareness in prolonged disorders of consciousness –a cross-sectional cohort study
Published in Disability and Rehabilitation, 2018
Kudret Yelden, Sophie Duport, Leon M. James, Agnieszka Kempny, Simon F. Farmer, Alex P. Leff, E. Diane Playford
This study highlights the importance of long-term follow up of patients with disorders of consciousness, regardless of the etiology, age of the patient, and time passed since the brain injury. Recovery of awareness in a third of patients over a long period of time, albeit with a poor functional outcome, supports the findings of recent studies showing that late recovery is possible [14] and it provides behavioral support for the concept that there may be long term axonal regrowth and neural plasticity in disorders of consciousness [30,31]. Our results further increase the ethical dilemmas faced by staff involved in making treatment decisions in this vulnerable patient group. The phenomenon of very late recovery of awareness has an important bearing on questions of withdrawal of artificial nutrition and hydration. Our study raises the question as to whether the word “permanent” is being used appropriately in the diagnostic term “Permanent Vegetative State” as reported in the recent Royal College of Physicians Guidelines. Prospective multi-center studies that involve a variety of rehabilitation and long-term care settings are now needed in order to comprehend long-term prognostic outcomes and mechanisms of recovery in severe PDOC states.
Survival and consciousness recovery are better in the minimally conscious state than in the vegetative state
Published in Brain Injury, 2018
Frédéric Faugeras, Benjamin Rohaut, Mélanie Valente, Jacobo Sitt, Sophie Demeret, Francis Bolgert, Nicolas Weiss, Alexandra Grinea, Clémence Marois, Marion Quirins, Athena Demertzi, Federico Raimondo, Damien Galanaud, Marie-Odile Habert, Denis Engemann, Louis Puybasset, Lionel Naccache
In a population of 67 patients suffering from a disorder of consciousness, and who were either in the VS/UWS or in the MCS, we showed that the initial diagnosis of consciousness impairment in ICUs conveys a strong prognostic value. This result probably captures an important determinant of prognosis because it holds in spite of the single consciousness assessment (covering a ~ 1 hour time-window of examination) performed in these patients at the early stage frequently associated with fast fluctuations of consciousness level. To the best of our knowledge, this result obtained in a prospective study was conducted on the largest sample of patients at the acute stage so far reported in the literature and confirms previous studies. It further strengthens the importance of an early and rigorous distinction of VS/UWS and MCS in terms of prognostic information. One limitation of our study is the single detailed neurobehavioural assessment at the inclusion stage. Given the notable fluctuations observed in these patients, one may wonder if we would not have underestimated some patients in the MCS as being in the VS/UWS. Note however that such a misclassification would have played against our findings. Therefore, by observing significant differences in terms of outcomes between patients in the MCS and the VS/UWS, we were able to emphasize the importance of initial neurobehavioural state.
Related Knowledge Centers
- Brain Death
- Coma
- Consciousness
- Delirium
- Differential Diagnosis
- Minimally Conscious State
- Dementia
- Vegetative State
- Locked-In Syndrome
- Medical Research