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Rubin MA, Lewis A, Creutzfeldt CJ, Shrestha GS, Boyle Q, Illes J, Jox RJ, Trevick S, Young MJ. Equity in Clinical Care and Research Involving Persons with Disorders of Consciousness. Neurocrit Care 2024; 41:345-356. [PMID: 38872033 DOI: 10.1007/s12028-024-02012-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2024] [Accepted: 05/09/2024] [Indexed: 06/15/2024]
Abstract
People with disorders of consciousness (DoC) are characteristically unable to synchronously participate in decision-making about clinical care or research. The inability to self-advocate exacerbates preexisting socioeconomic and geographic disparities, which include the wide variability observed across individuals, hospitals, and countries in access to acute care, expertise, and sophisticated diagnostic, prognostic, and therapeutic interventions. Concerns about equity for people with DoC are particularly notable when they lack a surrogate decision-maker (legally referred to as "unrepresented" or "unbefriended"). Decisions about both short-term and long-term life-sustaining treatment typically rely on neuroprognostication and individual patient preferences that carry additional ethical considerations for people with DoC, as even individuals with well thought out advance directives cannot anticipate every possible situation to guide such decisions. Further challenges exist with the inclusion of people with DoC in research because consent must be completed (in most circumstances) through a surrogate, which excludes those who are unrepresented and may discourage investigators from exploring questions related to this population. In this article, the Curing Coma Campaign Ethics Working Group reviews equity considerations in clinical care and research involving persons with DoC in the following domains: (1) access to acute care and expertise, (2) access to diagnostics and therapeutics, (3) neuroprognostication, (4) medical decision-making for unrepresented people, (5) end-of-life decision-making, (6) access to postacute rehabilitative care, (7) access to research, (8) inclusion of unrepresented people in research, and (9) remuneration and reciprocity for research participation. The goal of this discussion is to advance equitable, harmonized, guideline-directed, and goal-concordant care for people with DoC of all backgrounds worldwide, prioritizing the ethical standards of respect for autonomy, beneficence, and justice. Although the focus of this evaluation is on people with DoC, much of the discussion can be extrapolated to other critically ill persons worldwide.
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Affiliation(s)
- Michael A Rubin
- University of Texas Southwestern Medical School, Dallas, TX, USA
| | | | - Claire J Creutzfeldt
- Harborview Medical Center, Seattle, WA, USA
- University of Washington, Seattle, WA, USA
- Cambia Palliative Care Center of Excellence, Seattle, WA, USA
| | - Gentle S Shrestha
- Department of Critical Care Medicine, Tribhuvan University Teaching Hospital, Maharajgunj, Kathmandu, Nepal
| | - Quinn Boyle
- Neuroethics Canada, Division of Neurology, Department of Medicine, University of British Columbia, Vancouver, BC, Canada
| | - Judy Illes
- Neuroethics Canada, Division of Neurology, Department of Medicine, University of British Columbia, Vancouver, BC, Canada
| | - Ralf J Jox
- Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
| | | | - Michael J Young
- Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA.
- Division of Neurocritical Care, Department of Neurology, Center for Neurotechnology and Neurorecovery, Massachusetts General Hospital, Boston, USA.
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Young MJ, Kaplan TB, Alexander EK, Tolchin DW. Navigating the acute to post-acute transition with patients: a first characterization of medical student knowledge gaps in rehabilitation and post-acute care. Disabil Rehabil 2024; 46:3469-3474. [PMID: 37503888 DOI: 10.1080/09638288.2023.2240700] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2023] [Accepted: 07/21/2023] [Indexed: 07/29/2023]
Abstract
PURPOSE Clinical rehabilitation and post-acute care (PAC) learning experiences are not uniformly required within medical school core curricula in the United States or internationally. This study aims to characterize what medical students might know/need to know to support patients in the transition from acute hospitalization to post-acute rehabilitation settings. MATERIALS/METHODS The medical student cohort completing required clinical rotations in a United States quaternary care hospital system was provided a voluntary survey prompting reflection on experiences discharging patients to rehabilitation/PAC and related learning needs. Data were analyzed using descriptive statistics and qualitative grounded theory. RESULTS Response rate was 72% (39/54). All respondents reported at least one gap in rehabilitation/PAC knowledge, falling into 8 themes: daily experience of rehabilitation/PAC; determination of eligibility/screening processes; distinctions among levels of rehabilitation/PAC; insurance coverage/equity; rehabilitation/PAC clinical practice environment; post-rehabilitation/PAC discharge support; medical capabilities within PAC settings; developing rehabilitation goals. CONCLUSIONS Despite caring for patients discharged to post-acute rehabilitation settings, medical students lack essential knowledge about the process of rehabilitation and recovery, including patient eligibility for and service availability across PAC settings. Explicit rehabilitation/PAC education for medical students could enhance their ability to counsel and advocate for patients with disability and rehabilitation needs through care transitions.Implications for rehabilitationMedical students lack knowledge about rehabilitation and post-acute care that is important for helping patients navigate the acute to post-acute transition.Dedicated rehabilitation/post-acute care education could prepare trainees for counseling and advocating for patients during care transitions.Knowledge gaps identified in this study could inform development of curricular interventions to address medical student learning needs.
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Affiliation(s)
- Michael J Young
- Massachusetts General Hospital, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
| | - Tamara B Kaplan
- Harvard Medical School, Boston, MA, USA
- Brigham and Women's Hospital, Boston, MA, USA
| | - Erik K Alexander
- Harvard Medical School, Boston, MA, USA
- Brigham and Women's Hospital, Boston, MA, USA
| | - Dorothy W Tolchin
- Massachusetts General Hospital, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
- Spaulding Rehabilitation Hospital, Charlestown, MA, USA
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3
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Young MJ. Disorders of Consciousness Rehabilitation: Ethical Dimensions and Epistemic Dilemmas. Phys Med Rehabil Clin N Am 2024; 35:209-221. [PMID: 37993190 DOI: 10.1016/j.pmr.2023.06.016] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2023]
Abstract
Patients with disorders of consciousness who survive to discharge following severe acute brain injury may face profoundly complex medical, ethical, and psychosocial challenges during their courses of recovery and rehabilitation. Although issues encountered in caring for such patients during acute hospitalization have received substantial attention, ethical challenges that may arise in subacute and chronic phases have been underexplored. Shedding light on these issues, this article explores the landscape of normative issues in the course of treating and facilitating access to care for persons with disorders of consciousness during rehabilitation and examines potential implications for patients, clinicians, family members, and society.
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Affiliation(s)
- Michael J Young
- Department of Neurology, Massachusetts General Hospital, Center for Neurotechnology and Neurorecovery, 101 Merrimac Street, Suite 310, Boston, MA 02114, USA.
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Russell ME, Hammond FM, Murtaugh B. Prognosis and enhancement of recovery in disorders of consciousness. NeuroRehabilitation 2024; 54:43-59. [PMID: 38277313 DOI: 10.3233/nre-230148] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2024]
Abstract
Disorders of consciousness after severe brain injury encompass conditions of coma, vegetative state/unresponsive wakefulness syndrome, and minimally conscious state. DoC clinical presentation pose perplexing challenges to medical professionals, researchers, and families alike. The outcome is uncertain in the first weeks to months after a brain injury, with families and medical providers often making important decisions that require certainty. Prognostication for individuals with these conditions has been the subject of intense scientific investigation that continues to strive for valid prognostic indicators and algorithms for predicting recovery of consciousness. This manuscript aims to provide an overview of the current clinical landscape surrounding prognosis and optimizing recovery in DoC and the current and future research that could improve prognostic accuracy after severe brain injury. Improved understanding of these factors will aid healthcare professionals in providing optimal care, fostering hope, and advocating for ethical practices in the management of individuals with DoC.
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Affiliation(s)
- Mary E Russell
- Department of Physical Medicine and Rehabilitation, University of Texas McGovern Medical School, Houston, TX, USA
- TIRR Memorial Hermann - The Woodlands, Shenandoah, TX, USA
| | - Flora M Hammond
- Department of Physical Medicine and Rehabilitation, Indiana University School of Medicine, Indianapolis, IN, USA
- Rehabilitation Hospital of Indiana, Indianapolis, IN, USA
| | - Brooke Murtaugh
- Department of Rehabilitation Programs, Madonna Rehabilitation Hospitals, Lincoln, NE, USA
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Lewis A, Young MJ, Rohaut B, Jox RJ, Claassen J, Creutzfeldt CJ, Illes J, Kirschen M, Trevick S, Fins JJ. Ethics Along the Continuum of Research Involving Persons with Disorders of Consciousness. Neurocrit Care 2023; 39:565-577. [PMID: 36977963 PMCID: PMC11023737 DOI: 10.1007/s12028-023-01708-2] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2022] [Accepted: 02/23/2023] [Indexed: 03/30/2023]
Abstract
Interest in disorders of consciousness (DoC) has grown substantially over the past decade and has illuminated the importance of improving understanding of DoC biology; care needs (use of monitoring, performance of interventions, and provision of emotional support); treatment options to promote recovery; and outcome prediction. Exploration of these topics requires awareness of numerous ethics considerations related to rights and resources. The Curing Coma Campaign Ethics Working Group used its expertise in neurocritical care, neuropalliative care, neuroethics, neuroscience, philosophy, and research to formulate an informal review of ethics considerations along the continuum of research involving persons with DoC related to the following: (1) study design; (2) comparison of risks versus benefits; (3) selection of inclusion and exclusion criteria; (4) screening, recruitment, and enrollment; (5) consent; (6) data protection; (7) disclosure of results to surrogates and/or legally authorized representatives; (8) translation of research into practice; (9) identification and management of conflicts of interest; (10) equity and resource availability; and (11) inclusion of minors with DoC in research. Awareness of these ethics considerations when planning and performing research involving persons with DoC will ensure that the participant rights are respected while maximizing the impact and meaningfulness of the research, interpretation of outcomes, and communication of results.
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Affiliation(s)
- Ariane Lewis
- NYU Langone Medical Center, 530 First Avenue, Skirball-7R, New York, NY, 10016, USA.
| | - Michael J Young
- Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Benjamin Rohaut
- Inserm, CNRS, APHP - Hôpital de la Pitié Salpêtrière, Paris Brain Institute - ICM, DMU Neuroscience, Sorbonne University, Paris, France
| | - Ralf J Jox
- Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
| | - Jan Claassen
- New York Presbyterian Hospital, Columbia University, New York, NY, USA
| | - Claire J Creutzfeldt
- Harborview Medical Center, Seattle, WA, USA
- University of Washington, Seattle, WA, USA
- Cambia Palliative Care Center of Excellence, Seattle, WA, USA
| | - Judy Illes
- University of British Columbia, Vancouver, BC, Canada
| | | | | | - Joseph J Fins
- Weill Cornell Medical College, New York, NY, USA
- Yale Law School, New Haven, CT, USA
- Rockefeller University, New York, NY, USA
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6
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Birch J. Medical AI, inductive risk and the communication of uncertainty: the case of disorders of consciousness. JOURNAL OF MEDICAL ETHICS 2023:jme-2023-109424. [PMID: 37979975 DOI: 10.1136/jme-2023-109424] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/12/2023] [Accepted: 10/28/2023] [Indexed: 11/20/2023]
Abstract
Some patients, following brain injury, do not outwardly respond to spoken commands, yet show patterns of brain activity that indicate responsiveness. This is 'cognitive-motor dissociation' (CMD). Recent research has used machine learning to diagnose CMD from electroencephalogram recordings. These techniques have high false discovery rates, raising a serious problem of inductive risk. It is no solution to communicate the false discovery rates directly to the patient's family, because this information may confuse, alarm and mislead. Instead, we need a procedure for generating case-specific probabilistic assessments that can be communicated clearly. This article constructs a possible procedure with three key elements: (1) A shift from categorical 'responding or not' assessments to degrees of evidence; (2) The use of patient-centred priors to convert degrees of evidence to probabilistic assessments; and (3) The use of standardised probability yardsticks to convey those assessments as clearly as possible.
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Affiliation(s)
- Jonathan Birch
- Centre for Philosophy of Natural and Social Science, LSE, London, UK
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Weaver JA, Watters K, Cogan AM. Interventions Facilitating Recovery of Consciousness Following Traumatic Brain Injury: A Systematic Review. OTJR-OCCUPATION PARTICIPATION AND HEALTH 2023; 43:322-336. [PMID: 36047664 DOI: 10.1177/15394492221117779] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
People who experience disorders of consciousness (DoC) following a severe traumatic brain injury (TBI) have complex rehabilitation needs addressed by occupational therapy. To examine the effectiveness of interventions to improve arousal and awareness of people with DoC following a TBI. For this systematic review, we followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. We searched six databases in collaboration with a research librarian. Twenty-seven studies were included and grouped thematically. Multimodal sensory stimulation, familiar voices telling structured stories, and transcranial direct current stimulation had a moderate level of evidence. Multimodal sensory stimulation had the strongest evidence in support of its use in clinical practice. Occupational therapy practitioners should administer multimodal stimuli frequently as studies reported administering these interventions at least twice daily. Occupational therapy practitioners should incorporate personally relevant, meaningful, salient stimuli into interventions when treating patients with DoC.
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Affiliation(s)
| | | | - Alison M Cogan
- VA Greater Los Angeles Healthcare System, Los Angeles, CA, USA
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8
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Nekrasova JY, Kanarsky MM, Borisov IV, Pradhan P, Yankevich DS, Roshka SF, Petrova MV, Grechko AV. Post-Discharge Plight Of Patients With Chronic Disorders Of Consciousness: A Systematic Review Of Socioeconomic And Health Aspects. RUSSIAN OPEN MEDICAL JOURNAL 2022. [DOI: 10.15275/rusomj.2022.0412] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
Abstract
Objective — the presented study aims to systematize and structure significant information regarding the problems of patients with disorders of consciousness (DOC) and their families after discharge from the hospital, and to search for possible solutions. Material and Methods — to identify eligible studies, we searched the Medline database (via PubMed) for studies on socioeconomic and medical issues of patients with chronic DOC at the post-hospital stage of rehabilitation for the last 20 years. Results — we included 28 studies with 21 cohorts of patients from 7 different countries in our study. The components of informal caregiver burden and their impact on the quality of life were identified and systematized. These components include high physical load, high economic costs, vast time expenditures, strong emotional involvement, and a top level of expertise in caregiving, all of which are required from the relatives. Conclusion — It was affirmed, that the lack of healthcare system support was a major contributing factor to the overall burden. Our research also showed that delivering care without receiving information, advice, and training is extremely painful for family caregivers.
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Affiliation(s)
- Julia Yu. Nekrasova
- Federal Research and Clinical Center of Intensive Care Medicine and Rehabilitology, Moscow, Russia
| | - Mikhail M. Kanarsky
- Federal Research and Clinical Center of Intensive Care Medicine and Rehabilitology, Moscow, Russia
| | - Ilya V. Borisov
- Federal Research and Clinical Center of Intensive Care Medicine and Rehabilitology, Moscow, Russia
| | - Pranil Pradhan
- Federal Research and Clinical Center of Intensive Care Medicine and Rehabilitology, Moscow, Russia; Peoples’ Friendship University of Russia (RUDN University), Moscow, Russia
| | - Dmitry S. Yankevich
- Federal Research and Clinical Center of Intensive Care Medicine and Rehabilitology, Moscow, Russia
| | - Stanislav F. Roshka
- Federal Research and Clinical Center of Intensive Care Medicine and Rehabilitology, Moscow, Russia
| | - Marina V. Petrova
- Federal Research and Clinical Center of Intensive Care Medicine and Rehabilitology, Moscow, Russia; Peoples’ Friendship University of Russia (RUDN University), Moscow, Russia
| | - Andrey V. Grechko
- Federal Research and Clinical Center of Intensive Care Medicine and Rehabilitology, Moscow, Russia
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9
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Boissel A, Leblond F, Pinel-Jacquemin S, Petit P, Tasseau F, Vérin É. Caregivers of people with disorders of consciousness: Relationship continuity and rupture. EVOLUTION PSYCHIATRIQUE 2022. [DOI: 10.1016/j.evopsy.2022.01.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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10
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Young MJ, Bodien YG, Edlow BL. Ethical Considerations in Clinical Trials for Disorders of Consciousness. Brain Sci 2022; 12:211. [PMID: 35203974 PMCID: PMC8870384 DOI: 10.3390/brainsci12020211] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2022] [Revised: 01/28/2022] [Accepted: 01/28/2022] [Indexed: 11/30/2022] Open
Abstract
As the clinical trial landscape for patients with disorders of consciousness (DoC) expands, consideration of associated ethical challenges and opportunities is of ever-increasing importance. Responsible conduct of research in the vulnerable population of persons with DoC, including those with coma, vegetative state/unresponsive wakefulness syndrome (VS/UWS), minimally conscious state (MCS), covert cortical processing (CCP), and cognitive motor dissociation (CMD), demands proactive deliberation of unique ethical issues that may arise and the adoption of robust protections to safeguard patients, surrogates, and other key stakeholders. Here we identify and critically evaluate four central categories of ethical considerations in clinical trials involving participants with DoC: (1) autonomy, respect for persons and informed consent of individuals with liminal consciousness; (2) balancing unknown benefits and risks, especially considering the epistemological gap between behavior and consciousness that complicates ordinary ascription of subjective states; (3) disclosure to surrogates and clinical teams of investigational results pertaining to consciousness; and (4) justice considerations, including equitable access to clinical trial enrollment across communities and geographies. We outline guiding principles and research opportunities for clinicians, neuroethicists, and researchers engaged in DoC clinical trials to advance ethical study design and deployment in this complex yet crucial area of investigation.
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Affiliation(s)
- Michael J. Young
- Center for Neurotechnology and Neurorecovery, Department of Neurology, Harvard Medical School, Massachusetts General Hospital, Boston, MA 02114, USA; (Y.G.B.); (B.L.E.)
| | - Yelena G. Bodien
- Center for Neurotechnology and Neurorecovery, Department of Neurology, Harvard Medical School, Massachusetts General Hospital, Boston, MA 02114, USA; (Y.G.B.); (B.L.E.)
- Department of Physical Medicine and Rehabilitation, Harvard Medical School, Spaulding Rehabilitation Hospital, Charlestown, MA 02114, USA
| | - Brian L. Edlow
- Center for Neurotechnology and Neurorecovery, Department of Neurology, Harvard Medical School, Massachusetts General Hospital, Boston, MA 02114, USA; (Y.G.B.); (B.L.E.)
- Athinoula A. Martinos Center for Biomedical Imaging, Harvard Medical School, Massachusetts General Hospital, Charlestown, MA 02114, USA
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11
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Goss AL, Creutzfeldt CJ. Prognostication, Ethical Issues, and Palliative Care in Disorders of Consciousness. Neurol Clin 2022; 40:59-75. [PMID: 34798975 PMCID: PMC8672806 DOI: 10.1016/j.ncl.2021.08.005] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
Research advances in recent years have shown that some individuals with vegetative state or minimally conscious state can emerge to higher states of consciousness even years after injury. A minority of behaviorally unresponsive patients with vegetative state have also been shown to follow commands, or even communicate, using neuroimaging or electrophysiological techniques. These advances raise ethical questions that have important implications for clinical care. In this article, the authors argue that adopting a neuropalliative care approach can help clinicians provide ethical, compassionate care to these patients and their caregivers.
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Affiliation(s)
- Adeline L Goss
- Department of Neurology, University of California San Francisco, 505 Parnassus Avenue, Box 0114, San Francisco, CA 94143, USA.
| | - Claire J Creutzfeldt
- Department of Neurology, University of Washington, 325 Ninth Avenue, Seattle, WA 98104, USA
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12
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Young MJ, Bodien YG, Giacino JT, Fins JJ, Truog RD, Hochberg LR, Edlow BL. The neuroethics of disorders of consciousness: a brief history of evolving ideas. Brain 2021; 144:3291-3310. [PMID: 34347037 PMCID: PMC8883802 DOI: 10.1093/brain/awab290] [Citation(s) in RCA: 40] [Impact Index Per Article: 13.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2021] [Revised: 06/11/2021] [Accepted: 07/10/2021] [Indexed: 11/12/2022] Open
Abstract
Neuroethical questions raised by recent advances in the diagnosis and treatment of disorders of consciousness are rapidly expanding, increasingly relevant and yet underexplored. The aim of this thematic review is to provide a clinically applicable framework for understanding the current taxonomy of disorders of consciousness and to propose an approach to identifying and critically evaluating actionable neuroethical issues that are frequently encountered in research and clinical care for this vulnerable population. Increased awareness of these issues and clarity about opportunities for optimizing ethically responsible care in this domain are especially timely given recent surges in critically ill patients with prolonged disorders of consciousness associated with coronavirus disease 2019 around the world. We begin with an overview of the field of neuroethics: what it is, its history and evolution in the context of biomedical ethics at large. We then explore nomenclature used in disorders of consciousness, covering categories proposed by the American Academy of Neurology, the American Congress of Rehabilitation Medicine and the National Institute on Disability, Independent Living and Rehabilitation Research, including definitions of terms such as coma, the vegetative state, unresponsive wakefulness syndrome, minimally conscious state, covert consciousness and the confusional state. We discuss why these definitions matter, and why there has been such evolution in this nosology over the years, from Jennett and Plum in 1972 to the Multi-Society Task Force in 1994, the Aspen Working Group in 2002 and the 2018 American and 2020 European Disorders of Consciousness guidelines. We then move to a discussion of clinical aspects of disorders of consciousness, the natural history of recovery and ethical issues that arise within the context of caring for people with disorders of consciousness. We conclude with a discussion of key challenges associated with assessing residual consciousness in disorders of consciousness, potential solutions and future directions, including integration of crucial disability rights perspectives.
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Affiliation(s)
- Michael J Young
- Center for Neurotechnology and Neurorecovery,
Department of Neurology, Massachusetts General Hospital, Harvard Medical
School, Boston, MA 02114, USA
- Edmond J. Safra Center for Ethics, Harvard
University, Cambridge, MA 02138, USA
| | - Yelena G Bodien
- Center for Neurotechnology and Neurorecovery,
Department of Neurology, Massachusetts General Hospital, Harvard Medical
School, Boston, MA 02114, USA
- Department of Physical Medicine and Rehabilitation,
Spaulding Rehabilitation Hospital, Harvard Medical School, Charlestown, MA
02129, USA
| | - Joseph T Giacino
- Department of Physical Medicine and Rehabilitation,
Spaulding Rehabilitation Hospital, Harvard Medical School, Charlestown, MA
02129, USA
| | - Joseph J Fins
- Division of Medical Ethics, Weill Cornell Medical
College, New York, NY 10021, USA
- Yale Law School, New Haven,
Connecticut 06511, USA
| | - Robert D Truog
- Center for Bioethics, Harvard Medical
School, Boston, MA 02115, USA
| | - Leigh R Hochberg
- Center for Neurotechnology and Neurorecovery,
Department of Neurology, Massachusetts General Hospital, Harvard Medical
School, Boston, MA 02114, USA
- School of Engineering and Carney Institute for Brain
Science, Brown University, Providence, RI 02906, USA
- VA RR&D Center for Neurorestoration and
Neurotechnology, Department of Veterans Affairs Medical Center,
Providence, RI 02908, USA
| | - Brian L Edlow
- Center for Neurotechnology and Neurorecovery,
Department of Neurology, Massachusetts General Hospital, Harvard Medical
School, Boston, MA 02114, USA
- Athinoula A. Martinos Center for Biomedical Imaging,
Massachusetts General Hospital, Charlestown, MA 02129, USA
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13
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Garzón Diaz FA. Bioethical Aspects of Patients in a Minimally Conscious State. REVISTA LATINOAMERICANA DE BIOÉTICA 2021. [DOI: 10.18359/rlbi.5594] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022] Open
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14
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Research Needs for Prognostic Modeling and Trajectory Analysis in Patients with Disorders of Consciousness. Neurocrit Care 2021; 35:55-67. [PMID: 34236623 DOI: 10.1007/s12028-021-01289-y] [Citation(s) in RCA: 31] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2021] [Accepted: 05/22/2021] [Indexed: 12/18/2022]
Abstract
BACKGROUND The current state of the science regarding the care and prognosis of patients with disorders of consciousness is limited. Scientific advances are needed to improve the accuracy, relevance, and approach to prognostication, thereby providing the foundation to develop meaningful and effective interventions. METHODS To address this need, an interdisciplinary expert panel was created as part of the Coma Science Working Group of the Neurocritical Care Society Curing Coma Campaign. RESULTS The panel performed a gap analysis which identified seven research needs for prognostic modeling and trajectory analysis ("recovery science") in patients with disorders of consciousness: (1) to define the variables that predict outcomes; (2) to define meaningful intermediate outcomes at specific time points for different endotypes; (3) to describe recovery trajectories in the absence of limitations to care; (4) to harness big data and develop analytic methods to prognosticate more accurately; (5) to identify key elements and processes for communicating prognostic uncertainty over time; (6) to identify health care delivery models that facilitate recovery and recovery science; and (7) to advocate for changes in the health care delivery system needed to advance recovery science and implement already-known best practices. CONCLUSION This report summarizes the current research available to inform the proposed research needs, articulates key elements within each area, and discusses the goals and advances in recovery science and care anticipated by successfully addressing these needs.
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Sharma-Virk M, van Erp WS, Lavrijsen JCM, Koopmans RTCM. Intensive neurorehabilitation for patients with prolonged disorders of consciousness: protocol of a mixed-methods study focusing on outcomes, ethics and impact. BMC Neurol 2021; 21:133. [PMID: 33752631 PMCID: PMC7983203 DOI: 10.1186/s12883-021-02158-z] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2020] [Accepted: 03/15/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Prolonged disorders of consciousness (PDOC) are amongst the severest sequelae of acquired brain injury. Evidence regarding epidemiology and rehabilitation outcomes is scarce. These knowledge gaps and psychological distress in families of PDOC patients may complicate clinical decision-making. The complex PDOC care and associated moral dilemmas result in high workload in healthcare professionals. Since 2019, all PDOC patients in the Netherlands have access to intensive neurorehabilitation up to 2 years post-injury provided by one rehabilitation center and four specialized nursing homes. Systematic monitoring of quantitative rehabilitation data within this novel chain of care is done in a study called DOCTOR. The optimization of tailored PDOC care, however, demands a better understanding of the impact of PDOC on patients, their families and healthcare professionals and their views on rehabilitation outcomes, end-of-life decisions and quality of dying. The True Outcomes of PDOC (TOPDOC) study aims to gain insight in the qualitative outcomes of PDOC rehabilitation and impact of PDOC on patients, their families and healthcare professionals. METHODS Nationwide multicenter prospective cohort study in the settings of early and prolonged intensive neurorehabilitation with a two-year follow-up period, involving three study populations: PDOC patients > 16 years, patients' family members and healthcare professionals involved in PDOC care. Families' and healthcare professionals' views on quality of rehabilitation outcomes, end-of-life decisions and dying will be qualitatively assessed using comprehensive questionnaires and in-depth interviews. Ethical dilemmas will be explored by studying moral deliberations. The impact of providing care to PDOC patients on healthcare professionals will be studied in focus groups. DISCUSSION To our knowledge, this is the first nationwide study exploring quality of outcomes, end-of-life decisions and dying in PDOC patients and the impact of PDOC in a novel chain of care spanning the first 24 months post-injury in specialized rehabilitation and nursing home settings. Newly acquired knowledge in TOPDOC concerning quality of outcomes in PDOC rehabilitation, ethical aspects and the impact of PDOC will enrich quantitative epidemiological knowledge and outcomes arising from DOCTOR. Together, these projects will contribute to the optimization of centralized PDOC care providing support to PDOC patients, families and healthcare professionals.
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Affiliation(s)
- Manju Sharma-Virk
- Radboud Institute for Health Sciences; Department of Primary and Community Care, Radboud University Medical Centre, Nijmegen, The Netherlands.
- PZC Dordrecht, Dordrecht, The Netherlands.
| | - Willemijn S van Erp
- Radboud Institute for Health Sciences; Department of Primary and Community Care, Radboud University Medical Centre, Nijmegen, The Netherlands
- Accolade Zorg, Bosch en Duin, The Netherlands
- Libra Revalidatie & Audiologie, Tilburg, The Netherlands
| | - Jan C M Lavrijsen
- Radboud Institute for Health Sciences; Department of Primary and Community Care, Radboud University Medical Centre, Nijmegen, The Netherlands
| | - Raymond T C M Koopmans
- Radboud Institute for Health Sciences; Department of Primary and Community Care, Radboud University Medical Centre, Nijmegen, The Netherlands
- Joachim en Anna, Centre for Specialized Geriatric Care, Nijmegen, The Netherlands
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Boissel A, Leblond F, Pinel-Jacquemin S, Petit P, Tasseau F, Vérin É. Les proches aidants des personnes en état de conscience altérée : ruptures et continuité dans les relations. EVOLUTION PSYCHIATRIQUE 2021. [DOI: 10.1016/j.evopsy.2020.10.009] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
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17
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Estraneo A, Masotta O, Bartolo M, Pistoia F, Perin C, Marino S, Lucca L, Pingue V, Casanova E, Romoli A, Gentile S, Formisano R, Salvi GP, Scarponi F, De Tanti A, Bongioanni P, Rossato E, Santangelo A, Diana AR, Gambarin M, Intiso D, Antenucci R, Premoselli S, Bertoni M, De Bellis F. Multi-center study on overall clinical complexity of patients with prolonged disorders of consciousness of different etiologies. Brain Inj 2020; 35:1-7. [PMID: 33331792 DOI: 10.1080/02699052.2020.1861652] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/23/2023]
Abstract
Aim: to assess overall clinical complexity of patients with acquired disorders of consciousness (DoC) in vegetative state/unresponsive wakefulness syndrome (VS/UWS) vs. minimally conscious state- MCS) and in different etiologies..Design: Multi-center cross-sectional observational study.Setting: 23 intensive neurorehabilitation units.Subjects: 264 patients with DoC in the post-acute phase: VS/UWS = 141, and MCS = 123 due to vascular (n = 125), traumatic (n = 83) or anoxic (n = 56) brain injury.Main Measures: Coma Recovery Scale-Revised, and Disability Rating Scale (DRS); presence of medical devices (e.g., for eating or breathing); occurrence and severity of medical complications.Results: patients in DoC, and particularly those in VS/UWS, showed severe overall clinical complexity. Anoxic patients had higher overall clinical complexity, lower level of responsiveness/consciousness, higher functional disability, and higher needs of medical devices. Vascular patients had worse premorbid clinical comorbidities. The two etiologies showed a comparable rate of MC, higher than that observed in traumatic etiology.Conclusion: overall clinical complexity is significantly higher in VS/UWS than in MCS, and in non-traumatic vs. traumatic etiology. These findings could explain the worse clinical evolution reported in anoxic and vascular etiologies and in VS/UWS patients and contribute to plan patient-tailored care and rehabilitation programmes.
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Affiliation(s)
- A Estraneo
- Department of Acquired Brain Injury, IRCCS Fondazione Don Carlo Gnocchi, Florence, Italy.,Neurology Unit, Santa Maria Della Pietà General Hospital, Nola, Italy
| | - O Masotta
- Lab for DoC Study, Istituti Clinici Scientifici Maugeri IRCCS, SB S.p.A. Lab for DoC Study, Telese Terme, Italy
| | - M Bartolo
- Neurorehabilitation Unit, HABILITA Zingonia/Ciserano, Bergamo, Italy
| | - F Pistoia
- Department of Biotechnological and Applied Clinical Sciences, Neurological Institute, University of L'Aquila, L'Aquila, Italy
| | - C Perin
- Unità di Neuroriabilitazione Cognitiva, Istituti Clinici Zucchi, Carate Brianza, Italy
| | - S Marino
- IRCCS Centro Neurolesi "Bonino-Pulejo", Messina, Italy
| | - L Lucca
- Unità di Riabilitazione Gravi Cerebrolesioni, Istituto S. Anna, Crotone, Italy
| | - V Pingue
- Unità Medicina Riabilitativa Neuromotoria, Istituti Clinici Scientifici Maugeri IRCCS, SB S.p.A, Pavia, Italy
| | - E Casanova
- Casa dei Risvegli Luca De Nigris, IRCCS Ospedale Maggiore, Bologna, Italy
| | - A Romoli
- Department of Acquired Brain Injury, IRCCS Fondazione Don Carlo Gnocchi, Florence, Italy
| | - S Gentile
- Dip. di Riabilitazione, F.T. Camplani Clinica Ancelle Carità, Cremona, Italy
| | - R Formisano
- Unità Post-Coma e di Ricerca Traslazionale, IRCCS, Fondazione Santa Lucia, Rome, Italy
| | - G P Salvi
- U.F. Riabilitazione Neuromotoria, Istituto Clinico Quarenghi, S. Pellegrino Terme, Italy
| | - F Scarponi
- Dip. di Neurologia - UGCA, Ospedale S. Giovanni Battista, Foligno, Italy
| | - A De Tanti
- Centro Cardinal Ferrari, S. Stefano Riabilitazione, Fontanellato di Parma, Italy
| | - P Bongioanni
- Severe Acquired Brain Injuries Dept Section, Integrated Care Dept of Medical Specialties, Azienda Ospedaliero-Universitaria Pisana, Pisa, Italy
| | - E Rossato
- Centro Medicina del Sonno, Ospedale Sacro Cuore Don Calabria, Verona, Italy
| | - A Santangelo
- Unit for Severe Acquired Brain Injuries, Rehabilitation Dept, Giuseppe Giglio Foundation, Cefalù, Italy
| | - A R Diana
- Dip. Neuroscienze e Riabilitazione, Azienda Ospedaliera Brotzu, Cagliari, Italy
| | - M Gambarin
- Unità Medicina Fisica e Riabilitazione, Ospedale Riabilitativo Di Marzana, Verona, Italy
| | - D Intiso
- Unità di Medicina Fisica e Neuroriabilitazione, IRCCS "Casa Sollievo della Sofferenza", San Giovanni Rotondo, Italy
| | - R Antenucci
- Unità di Medicina Riabilitativa Intensiva, Ospedale Castel San Giovanni, Italy
| | - S Premoselli
- Struttura di Riabilitazione Neuromotoria, Presidio Ospedaliero Vimercate, Monza, Italy
| | - M Bertoni
- Presidio di Riabilitazione Neuromotoria, Azienda Socio Sanitaria Territoriale dei Sette Laghi, Cuasso Al Monte, Italy
| | - F De Bellis
- Dept. of Acquired Brain Injury, Fondazione Don Carlo Gnocchi, Sant'Angelo dei Lombardi, Italy
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18
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Minimum Competency Recommendations for Programs That Provide Rehabilitation Services for Persons With Disorders of Consciousness: A Position Statement of the American Congress of Rehabilitation Medicine and the National Institute on Disability, Independent Living and Rehabilitation Research Traumatic Brain Injury Model Systems. Arch Phys Med Rehabil 2020; 101:1072-1089. [PMID: 32087109 DOI: 10.1016/j.apmr.2020.01.013] [Citation(s) in RCA: 35] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2020] [Revised: 01/27/2020] [Accepted: 01/28/2020] [Indexed: 11/24/2022]
Abstract
Persons who have disorders of consciousness (DoC) require care from multidisciplinary teams with specialized training and expertise in management of the complex needs of this clinical population. The recent promulgation of practice guidelines for patients with prolonged DoC by the American Academy of Neurology, American Congress of Rehabilitation Medicine (ACRM), and National Institute on Disability, Independent Living, and Rehabilitation Research (NIDILRR) represents a major advance in the development of care standards in this area of brain injury rehabilitation. Implementation of these practice guidelines requires explication of the minimum competencies of clinical programs providing services to persons who have DoC. The Brain Injury Interdisciplinary Special Interest Group of the ACRM, in collaboration with the Disorders of Consciousness Special Interest Group of the NIDILRR-Traumatic Brain Injury Model Systems convened a multidisciplinary panel of experts to address this need through the present position statement. Content area-specific workgroups reviewed relevant peer-reviewed literature and drafted recommendations which were then evaluated by the expert panel using a modified Delphi voting process. The process yielded 21 recommendations on the structure and process of essential services required for effective DoC-focused rehabilitation, organized into 4 categories: diagnostic and prognostic assessment (4 recommendations), treatment (11 recommendations), transitioning care/long-term care needs (5 recommendations), and management of ethical issues (1 recommendation). With few exceptions, these recommendations focus on infrastructure requirements and operating procedures for the provision of DoC-focused neurorehabilitation services across subacute and postacute settings.
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19
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van Erp WS, Lavrijsen JCM, Vos PE, Laureys S, Koopmans RTCM. Unresponsive wakefulness syndrome: Outcomes from a vicious circle. Ann Neurol 2020; 87:12-18. [PMID: 31675139 PMCID: PMC6972677 DOI: 10.1002/ana.25624] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2019] [Revised: 10/13/2019] [Accepted: 10/14/2019] [Indexed: 11/07/2022]
Affiliation(s)
- Willemijn S. van Erp
- Department of Primary and Community CareRadboud University Medical Center, Radboud Institute for Health SciencesNijmegenthe Netherlands
- Coma Science Group, GIGA Consciousness, University of LiègeLiègeBelgium
| | - Jan C. M. Lavrijsen
- Department of Primary and Community CareRadboud University Medical Center, Radboud Institute for Health SciencesNijmegenthe Netherlands
| | - Pieter E. Vos
- Department of NeurologySlingeland HospitalDoetinchemthe Netherlands
| | - Steven Laureys
- Coma Science Group, GIGA ConsciousnessUniversity of LiègeLiègeBelgium
| | - Raymond T. C. M. Koopmans
- Department of Primary and Community CareRadboud University Medical Center, Radboud Institute for Health Sciences, and Joachim en Anna Center for Specialized Geriatric CareNijmegenthe Netherlands
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20
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Bernat JL. Clinical Decision‐Making for Patients with Disorders of Consciousness. Ann Neurol 2019; 87:19-21. [PMID: 31688951 DOI: 10.1002/ana.25636] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2019] [Accepted: 11/01/2019] [Indexed: 11/08/2022]
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21
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Barra ME, Izzy S, Sarro-Schwartz A, Hirschberg RE, Mazwi N, Edlow BL. Stimulant Therapy in Acute Traumatic Brain Injury: Prescribing Patterns and Adverse Event Rates at 2 Level 1 Trauma Centers. J Intensive Care Med 2019; 35:1196-1202. [PMID: 30966863 DOI: 10.1177/0885066619841603] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
BACKGROUND/OBJECTIVE Pharmacological stimulant therapies are routinely administered to promote recovery in patients with subacute and chronic disorders of consciousness (DoC). However, utilization rates and adverse drug event (ADE) rates of stimulant therapies in patients with acute DoC are unknown. We aimed to determine the frequency of stimulant use and associated ADEs in intensive care unit (ICU) patients with acute DoC caused by traumatic brain injury (TBI). METHODS We retrospectively identified patients with TBI admitted to the ICU at 2 level 1 trauma centers between 2015 and 2018. Patients were included if they were stimulant naive at baseline and received amantadine, methylphenidate, or modafinil during ICU admission. Stimulant dose reduction or discontinuation during ICU admission was considered a surrogate marker of an ADE. Targeted chart review was performed to identify reasons for dose reduction or discontinuation. RESULTS Forty-eight of 608 patients with TBI received pharmacological stimulant therapy (7.9%) during the study period. Most patients were diagnosed with severe TBI at presentation (60.4%), although stimulants were also administered to patients with moderate (14.6%) and mild (25.0%) TBI. The median time of stimulant initiation was 11 days post-injury (range: 2-28 days). Median Glasgow Coma Scale score at the time of stimulant initiation was 9 (range: 4-15). Amantadine was the most commonly prescribed stimulant (85.4%) followed by modafinil (14.6%). Seven (14.6%) patients required stimulant dose reduction or discontinuation during ICU admission. The most common ADE resulting in therapy modification was delirium/agitation (n = 2), followed by insomnia (n = 1), anxiety (n = 1), and rash (n = 1); the reason for therapy modification was undocumented in 2 patients. CONCLUSIONS Pharmacological stimulant therapy is infrequently prescribed but well tolerated in ICU patients with acute TBI at level 1 trauma centers. These retrospective observations provide the basis for prospective studies to evaluate the safety, optimal dose range, and efficacy of stimulant therapies in this population.
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Affiliation(s)
- Megan E Barra
- Department of Pharmacy, 2348Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Saef Izzy
- Department of Neurology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Aliyah Sarro-Schwartz
- Department of Neurology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Ronald E Hirschberg
- Department of Physical Medicine and Rehabilitation, 2348Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Nicole Mazwi
- Department of Physical Medicine and Rehabilitation, 2348Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Brian L Edlow
- Department of Neurology, Center for Neurotechnology and Neurorecovery, 2348Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA.,Athinoula A. Martinos Center for Biomedical Imaging, 2348Massachusetts General Hospital, Charlestown, MA, USA
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22
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Abstract
Drawing upon sources in neuroethics, civil rights, and disability rights law, we argue for the reintegration of people with severe brain injury back into the nexus of their families and communities consistent with the Americans with Disabilities Act (ADA) and the UN Convention on the Rights of Persons with Disabilities, both of which call for the maximal integration of people with disability into society. To this end, we offer a rights-based argument to address the care of people with severe brain injury. Instead of viewing the provision of rehabilitation as a reimbursement issue, which it surely is, we argue that it can be productively understood as a question of civil rights for a population generally segregated from the medical mainstream and from society itself. Their segregation in the chronic care sector constitutes disrespect for persons, made all the more consequential because recent advances in brain injury rehabilitation make reintegration into civil society an aspirational, if not achievable goal.
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Affiliation(s)
- Joseph J Fins
- a Division of Medical Ethics , Weill Medical College of Cornell University , New York , NY.,b The Consortium for the Advanced Study of Brain Injury, Weill Cornell Medical College , New York , NY.,c The Rockefeller University , New York , NY.,d Solomon Center for Health Law and Policy , Yale Law School , New Haven , CT
| | - Megan S Wright
- a Division of Medical Ethics , Weill Medical College of Cornell University , New York , NY.,b The Consortium for the Advanced Study of Brain Injury, Weill Cornell Medical College , New York , NY.,d Solomon Center for Health Law and Policy , Yale Law School , New Haven , CT
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23
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Abstract
In the 2015 David Kopf Lecture on Neuroethics of the Society for Neuroscience, Dr. Joseph Fins presents his work on neuroethics and disorders of consciousness through the experience of Maggie and Nancy Worthen, a young woman who sustained a severe brain injury and her mother who cared for her. The central protagonists in his book, Rights Come to Mind: Brain Injury, Ethics and the Struggle for Consciousness (Cambridge University Press, 2015), their experience is emblematic of the challenges faced by families touched by severe brain injury and the possibility for improved diagnosis and treatment offered by progress in neuroscience. By telling their story, and those of other families interviewed as part of the research for Rights Come to Mind, Fins calls for improved care for this population arguing that this is both an access to care issue and a civil and disability rights issue worthy of greater societal attention.
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Moretta P, Masotta O, Crispino E, Castronovo G, Ruvolo S, Montalbano C, Loreto V, Trojano L, Estraneo A. Psychological distress is associated with altered cognitive functioning in family caregivers of patients with disorders of consciousness. Brain Inj 2017; 31:1088-1093. [PMID: 28414249 DOI: 10.1080/02699052.2017.1290278] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
OBJECTIVES To analyse the possible presence of reduced cognitive efficiency in family caregivers of patients with prolonged disorders of consciousness (DOC). SUBJECTS The participants were 27 caregivers of 25 patients with DOC admitted to the severe brain injury units of the ICS Maugeri, Institutes of Telese Terme and Sciacca, Italy. METHODS We examined cognitive functions such as short- and long-term memory, executive functions and attention by means of standardized tests. We also assessed features of psychological distress such as anxiety, depression, psychophysiological symptoms, prolonged grief disorder, psychological burden and quality of life. All scores on neuropsychological tests were compared with those of the 15 matched control subjects. RESULTS Enrolled family caregivers showed high frequency of clinically relevant depressive symptoms and anxiety; half of them met the criteria for prolonged grief disorder. Caregivers achieved scores lower than the matched controls on tests for selective attention, verbal fluency and long-term spatial memory. CONCLUSIONS Family caregivers' burden is associated with a reduced efficiency of selected executive measures and visuospatial learning. These results emphasize the need for appropriate psychological and cognitive supporting therapies for family caregivers of patients with DOC, also considering their delicate involvement in clinical decision-making and in providing care.
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Affiliation(s)
- P Moretta
- a Disorders of Consciousness Laboratory, ICS Maugeri, IRCCS , Scientific Institute of Telese Terme , Telese Terme , Italy
| | - O Masotta
- a Disorders of Consciousness Laboratory, ICS Maugeri, IRCCS , Scientific Institute of Telese Terme , Telese Terme , Italy
| | - E Crispino
- a Disorders of Consciousness Laboratory, ICS Maugeri, IRCCS , Scientific Institute of Telese Terme , Telese Terme , Italy
| | - G Castronovo
- b ICS Maugeri, Neurorehabilitation Unit , Presidio Sanitario di Sciacca , Sciacca , Italy
| | - S Ruvolo
- b ICS Maugeri, Neurorehabilitation Unit , Presidio Sanitario di Sciacca , Sciacca , Italy
| | - C Montalbano
- b ICS Maugeri, Neurorehabilitation Unit , Presidio Sanitario di Sciacca , Sciacca , Italy
| | - V Loreto
- a Disorders of Consciousness Laboratory, ICS Maugeri, IRCCS , Scientific Institute of Telese Terme , Telese Terme , Italy
| | - L Trojano
- a Disorders of Consciousness Laboratory, ICS Maugeri, IRCCS , Scientific Institute of Telese Terme , Telese Terme , Italy.,c Neuropsychology Laboratory, Department of Psychology , University of Campania 'Luigi Vanvitelli' , Caserta , Italy
| | - A Estraneo
- a Disorders of Consciousness Laboratory, ICS Maugeri, IRCCS , Scientific Institute of Telese Terme , Telese Terme , Italy
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Yelden K, Sargent S, Samanta J. Understanding the decision-making environment for people in minimally conscious state. Neuropsychol Rehabil 2017; 28:1415-1426. [DOI: 10.1080/09602011.2017.1310657] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Affiliation(s)
- Kudret Yelden
- Research Department, Royal Hospital for Neuro-disability, London, UK
| | - Sarah Sargent
- School of Law, University of Buckingham, Buckingham, UK
| | - Jo Samanta
- Leicester De Montfort Law School, De Montfort University, Leicester, UK
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26
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Soeterik SM, Connolly S, Playford ED, Duport S, Riazi A. The psychological impact of prolonged disorders of consciousness on caregivers: a systematic review of quantitative studies. Clin Rehabil 2017; 31:1374-1385. [PMID: 28933608 DOI: 10.1177/0269215517695372] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
OBJECTIVE Systematic review of the nature, frequency and severity of psychological experiences of people who have a close relationship with a person with a prolonged disorder of consciousness. DATA SOURCES Cochrane Library, Web of Science, PsycINFO, PubMed, Embase®, MEDLINE®, Allied and Complementary Medicine™, were searched from inceptions until December 2016 with additional hand searching of reference lists of included articles. REVIEW METHODS Studies were included that used quantitative methodologies and psychological measures to investigate experiences. The PRISMA statement was followed with inclusion criteria set a priori. A data synthesis summarized psychological constructs studied. RESULTS A total of 18 studies (ranging between n = 16-487 participants) met the inclusion criteria with 15 of 18 studies focused on the primary caregiver. A total of 23 standardized psychological measures were identified to assess four primary psychological constructs: Loss and grief, psychological wellbeing changes, burden and use of coping strategies. CONCLUSIONS Small sample sizes, limited variables and reliance on observational methods affected quality. Caregivers do find ways to manage independently, but some exhibit clinically significant psychological distress that does not change over time alone and may get worse.
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Affiliation(s)
- Sonja M Soeterik
- 1 Department of Psychology, Royal Holloway University of London, Egham, UK.,2 Institute of Neuro-palliative Rehabilitation, Royal Hospital for Neuro-disability, London, UK
| | - Sarah Connolly
- 3 Ascot Rehab, Royal Hospital for Neuro-disability London, Surrey, UK
| | - E Diane Playford
- 2 Institute of Neuro-palliative Rehabilitation, Royal Hospital for Neuro-disability, London, UK.,4 Warwick Medical School, University of Warwick, Coventry, UK
| | - Sophie Duport
- 2 Institute of Neuro-palliative Rehabilitation, Royal Hospital for Neuro-disability, London, UK
| | - Afsane Riazi
- 1 Department of Psychology, Royal Holloway University of London, Egham, UK
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Parent Perceptions of How Nurse Encounters Can Provide Caring Support for the Family in Early Acute Care After Children's Severe Traumatic Brain Injury. J Neurosci Nurs 2016; 48:E2-E15. [PMID: 26871242 DOI: 10.1097/jnn.0000000000000192] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE A child's severe traumatic brain injury (TBI) creates a family crisis requiring extensive cultural, informational, psychological, and environmental support. Nurses need to understand parents' expectations of caring in early acute care so they can tailor their attitudes, beliefs, and behaviors appropriately to accommodate the family's needs. METHODS In a previous qualitative study of 42 parents or caregivers from 37 families of children with moderate-to-severe TBI, parents of children with severe TBI (n = 25) described their appraisals of nurse caring and uncaring behaviors in early acute care. Swanson's theory of caring was used to categorize parents' descriptions to inform nursing early acute care practices and family-centered care. RESULTS Caring nurse encounters included (a) involving parents in the care of their child and reflecting on all sociocultural factors shaping family resources and responses (knowing); (b) respecting that family grief can be co-mingled with resilience and that parents are typically competent to be involved in decision making (maintaining belief); (d) actively listening and engaging parents to fully understand family values and needs (being with); (e) decreasing parents' workload to get information and emotional support and provide a safe cultural, psychological, and physical environment for the family (doing for); and (f) providing anticipatory guidance to navigate the early acute care system and giving assistance to learn and adjust to their situation (enabling). CONCLUSION Application of Swanson's caring theory is prescriptive in helping individual nurses and early acute care systems to meet important family needs after children's severe TBI.
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Becker DA, Schiff ND, Becker LB, Holmes MG, Fins JJ, Horowitz JM, Devinsky O. A major miss in prognostication after cardiac arrest: Burst suppression and brain healing. EPILEPSY & BEHAVIOR CASE REPORTS 2016; 7:1-5. [PMID: 28053858 PMCID: PMC5198796 DOI: 10.1016/j.ebcr.2016.09.004] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/14/2016] [Revised: 09/12/2016] [Accepted: 09/13/2016] [Indexed: 11/18/2022]
Abstract
We report a case with therapeutic hypothermia after cardiac arrest where meaningful recovery far exceeded anticipated negative endpoints following cardiac arrest with loss of brainstem reflexes and subsequent status epilepticus. This man survived and recovered after an out-of-hospital cardiac arrest followed by a 6-week coma with absent motor responses and 5 weeks of burst suppression. Standard criteria suggested no chance of recovery. His recovery may relate to the effect of burst-suppression on EEG to rescue neurons near neuronal cell death. Further research to understand the mechanisms of therapeutic hypothermia and late restoration of neuronal functional capacity may improve prediction and aid end-of-life decisions after cardiac arrest.
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Affiliation(s)
- Danielle A. Becker
- Department of Neurology, Hospital of the University of Pennsylvania, Philadelphia, PA, United States
| | - Nicholas D. Schiff
- Department of Neurology, Weill Cornell Medical Center, New York, NY, United States
| | - Lance B. Becker
- Department of Emergency Medicine, Hospital of the University of Pennsylvania, Philadelphia, PA, United States
| | - Manisha G Holmes
- Department of Neurology, New York University Medical Center, New York, NY, United States
| | - Joseph J. Fins
- Department of Internal Medicine, Weill Cornell Medical Center, New York, NY, United States
| | - James M. Horowitz
- Division of Cardiology, Department of Internal Medicine, Weill Cornell Medical Center, New York, NY, United States
| | - Orrin Devinsky
- Department of Neurology, New York University Medical Center, New York, NY, United States
- Corresponding author at: Department of Neurology, New York University Medical Center, 223 East 34th Street, New York, NY 10016, United States.Department of NeurologyNew York University Medical Center223 East 34th StreetNew YorkNY10016United States
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Individuals With Traumatic Brain Injury and Their Significant Others' Perceptions of Information Given About the Nature and Possible Consequences of Brain Injury. Prof Case Manag 2016; 21:22-33; quiz E3-4. [DOI: 10.1097/ncm.0000000000000121] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Jox RJ, Kuehlmeyer K, Klein AM, Herzog J, Schaupp M, Nowak DA, Koenig E, Müller F, Bender A. Diagnosis and Decision Making for Patients With Disorders of Consciousness: A Survey Among Family Members. Arch Phys Med Rehabil 2015; 96:323-30. [DOI: 10.1016/j.apmr.2014.09.030] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2014] [Revised: 09/04/2014] [Accepted: 09/23/2014] [Indexed: 01/09/2023]
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Rosenbaum AM, Giacino JT. Clinical management of the minimally conscious state. HANDBOOK OF CLINICAL NEUROLOGY 2015; 127:395-410. [PMID: 25702230 DOI: 10.1016/b978-0-444-52892-6.00025-8] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/04/2023]
Abstract
The minimally conscious state (MCS) was defined as a disorder of consciousness (DoC) distinct from the vegetative state more than a decade ago. While this condition has become widely recognized, there are still no guidelines to steer the approach to assessment and treatment. The development of evidence-based practice guidelines for MCS has been hampered by ambiguity around the concept of consciousness, the lack of accurate methods of assessment, and the dearth of well-designed clinical trials. This chapter provides a critical review of existing assessment procedures, critically reviews available treatment options and identifies knowledge gaps. We close with practice-based recommendations for a rational approach to clinical management of this challenging population.
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Affiliation(s)
| | - Joseph T Giacino
- Department of Physical Medicine and Rehabilitation, Harvard Medical School and Spaulding Rehabilitation Hospital, Boston, MA, USA.
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32
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Assessment of patients with disorder of consciousness: do different Coma Recovery Scale scoring correlate with different settings? J Neurol 2014; 261:2378-86. [DOI: 10.1007/s00415-014-7478-5] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2014] [Revised: 08/20/2014] [Accepted: 08/21/2014] [Indexed: 12/11/2022]
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Brogan ME, Provencio JJ. Spectrum of catastrophic brain injury: coma and related disorders of consciousness. J Crit Care 2014; 29:679-82. [PMID: 24930368 DOI: 10.1016/j.jcrc.2014.04.014] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2014] [Accepted: 04/20/2014] [Indexed: 10/25/2022]
Affiliation(s)
- Michael E Brogan
- Cerebrovascular Center, Neurological Institute, Cleveland Clinic, Cleveland, OH
| | - J Javier Provencio
- Cerebrovascular Center, Neurological Institute, Cleveland Clinic, Cleveland, OH.
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Howe EG. Ethically Optimal Interventions with Impaired Patients. THE JOURNAL OF CLINICAL ETHICS 2014. [DOI: 10.1086/jce201425101] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
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Disorders of consciousness after acquired brain injury: the state of the science. Nat Rev Neurol 2014; 10:99-114. [PMID: 24468878 DOI: 10.1038/nrneurol.2013.279] [Citation(s) in RCA: 445] [Impact Index Per Article: 44.5] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
The concept of consciousness continues to defy definition and elude the grasp of philosophical and scientific efforts to formulate a testable construct that maps to human experience. Severe acquired brain injury results in the dissolution of consciousness, providing a natural model from which key insights about consciousness may be drawn. In the clinical setting, neurologists and neurorehabilitation specialists are called on to discern the level of consciousness in patients who are unable to communicate through word or gesture, and to project outcomes and recommend approaches to treatment. Standards of care are not available to guide clinical decision-making for this population, often leading to inconsistent, inaccurate and inappropriate care. In this Review, we describe the state of the science with regard to clinical management of patients with prolonged disorders of consciousness. We review consciousness-altering pathophysiological mechanisms, specific clinical syndromes, and novel diagnostic and prognostic applications of advanced neuroimaging and electrophysiological procedures. We conclude with a provocative discussion of bioethical and medicolegal issues that are unique to this population and have a profound impact on care, as well as raising questions of broad societal interest.
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