Unlocking the Voices of Patients with Severe Brain Injury

Perspectives on consciousness in patients with disorders of consciousness from brain injury: group concept mapping study across clinic, research, and families

BACKGROUND

An effective healthcare system depends on clinic, research, and patient/relatives interactions. Such interactions may at their core be challenged by misalignments of concepts and the practices that constitute them. The concept of consciousness and what is experienced and understood as signs of consciousness in patients with severe acquired brain injury is one of these potential areas of misalignment. Different perspectives and experiences of consciousness are challenging the delivery of care and the high-stake decision-making process on the potential withdrawal of treatment. The enhanced uncertainties call for reflections on how key stakeholders perceive and identify consciousness in current clinical encounters and practice.

METHODS

The study empirically explores the actual experiences and conceptions of consciousness concerning patients with disorders of consciousness (DoC) from the perspectives of researchers, health professionals, and relatives of patients, to understand the challenges of the diversity of understandings of consciousness. Engaging the stakeholders by employing Group Concept Mapping methodology, the study developed a situated conceptual map, which reflects nuances and the importance of perspectives on and signs of consciousness.

RESULTS

Twenty-seven participants contributed to the generation of ideas, 14 took part in the structuring of statements and 10 took part in the validation meeting to interpret the cluster rating map. A total of 85 unique statements were identified and organized into six clusters: (1) Presence, (2) Intentional Activity, (3) Experience of self, (4) Participation in Social Interaction, (5) (Repeated) Response, and (6) Unspecific Reaction. The conceptual mapping demonstrates an extensive overlap in perspectives on consciousness among participants, prioritizing signs that are observable at the bedside.

CONCLUSIONS

The study provides a first step toward a future framework for the difficult process of decision-making concerning a segment of patients with DoC. The study highlights the importance of repeatable signs of consciousness observed at the bedside and the patient's ability to participate in social interactions, while also considering the importance of non-clinically observable signs of consciousness.

Deciding with Others: Interdependent Decision-Making

Over the course of human life, health care decision-making is often interdependent. In this article, we use "interdependence" to refer to patients' engagement of nonclinicians-for example, family members or trusted friends-to reach health care decisions. Interdependence, we suggest, is common for patients in all stages of life, from early childhood to late adulthood. This view contrasts with the common bioethical assumption that medical decisions are either wholly independent or dependent and that independence or dependence is tightly coupled with a person's decision-making capacity. In this article, we array various approaches to decision-making along a continuum of interdependence. An appreciation of this continuum can empower patients and elucidate ethical challenges that arise when people transition between different kinds of interdependence across the life span.

Treatment Trials in Disorders of Consciousness: Challenges and Future Directions

The evidence base supporting treatment interventions for patients with disorders of consciousness is limited, and rigorous treatment trials are needed to guide future management of this complex patient population. There are many potential study designs that can be employed to develop this evidence, but the process of selecting the optimal study design is challenging. This article reviews common obstacles that impede research progress in this population and a range of study designs that may be employed. In addition, we consider how the particular practical and scientific obstacles may drive selection of the optimal design and, in particular, how the optimal design changes as treatment research proceeds along the translational continuum from mechanistic discovery to real-world clinical impact.

Empowering the voiceless. Disorders of consciousness, neuroimaging and supported decision-making

Patients suffering from (Prolonged) Disorder of Consciousness are deemed incompetent to give valid informed consent due to the presumed impairment of their cognitive functions and the impossibility to communicate with them. Neuroscientists have, however, discovered ways in which communication with some of these patients might be possible by using neuroimaging. This would for the first time make it possible to include them in the decision-making on their own medical treatment. In this article, I elaborate on the prospect of communicating with patients with impaired consciousness in order to obtain their informed consent. I first map the current state-of-the-art in neuroimaging research that exhibits the possibility of communicating with some of these patients. Secondly, I examine how obtaining informed consent from these patients might be possible, given that the specificities and limitations of communication via neuroimaging render the task of assessing their competence rather difficult. Thirdly, I identify some of the important ethical and legal considerations that have to be taken into account before introducing neuroimaging in clinical practice as a means to obtain informed consent. Lastly, I look into the concept of supported decision-making and how this concept relates to the use of neurotechnology to support minimally conscious patients in their abilities to decide over their own medical treatment.