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Høybye MT, Andersen LM, Boelsbjerg HB. Making It Count - Tracing Signs of Consciousness and Potentiality in Severe Brain Injury in Denmark. Med Anthropol 2024; 43:115-129. [PMID: 38206318 DOI: 10.1080/01459740.2023.2300080] [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: 01/12/2024]
Abstract
Healthcare professionals use various technologies to evaluate and support patients who have suffered severe brain injuries. They integrate monitoring and sensory assessments into their clinical practice, and these assessments can have an impact on treatment decisions and prognostication. Responses from patients during different interactions are interpreted as "signs of consciousness" when considered contextually relevant. This study is based on anthropological fieldwork conducted in specialized Danish intensive care units, where we explore how signs of consciousness are made to count through practices of enactment. We ethnographically trace how the clinical concept of potential influences the interpretation of signs of consciousness as a complex biosocial practice based on the biomedical assumption that consciousness is a vital indicator of what makes a life. The article provides insights into the potential for recovery as an emergent biosocial practice and contributes to a broader discussion within medical anthropology of the moral landscapes of clinical and experimental borderlands.
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Affiliation(s)
- Mette Terp Høybye
- Interacting Minds Centre, Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
- Elective Surgery Center, Silkeborg Regional Hospital, Silkeborg, Denmark
| | - Lise Marie Andersen
- Interacting Minds Centre, Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
- Elective Surgery Center, Silkeborg Regional Hospital, Silkeborg, Denmark
| | - Hanne Bess Boelsbjerg
- Interacting Minds Centre, Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
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Zulato E, Montali L, Castro P. Regulating liminality: Making sense of the vegetative state and defining the limits of end-of-life action. BRITISH JOURNAL OF SOCIAL PSYCHOLOGY 2023; 62:1733-1752. [PMID: 37222294 DOI: 10.1111/bjso.12653] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2022] [Accepted: 05/04/2023] [Indexed: 05/25/2023]
Abstract
Persistently alive but unaware, vegetative state patients are stuck in the transition between life and death - that is, in a liminal hotspot. This condition raises complex ethical and legal dilemmas concerning end-of-life action. Drawing on social representations (SRs) and the liminality framework, our research investigated how the vegetative state was constructed within the Italian parliamentary debates discussing end-of-life bills (2009-2017). We aimed to understand (1) how political groups represented the vegetative state, (2) how they legitimised different end-of-life bills and (3) came to terms with the issue of liminal hotspots. By dialogically analysing three debates (No. of interventions = 98), we identified six themes and discursive aims allowing parliamentarians to differently represent the vegetative state and support different courses of action. In turn, we identified new features of the psycho-social processes generating SRs: the dialogical tensions between anchoring and de-anchoring. Results corroborated the idea that de-paradoxifying liminality relies on group sense-making and, thus, different political leanings differently addressed the liminality of the vegetative state. We also reveal a novel feature of dealing with liminal hotspots informing the psycho-social literature that applies when a decision needs to be taken, such as in the case of crafting a law: moving from the paradox.
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Affiliation(s)
- Edoardo Zulato
- Department of Psychology, University of Milano-Bicocca, Milano, Italy
| | - Lorenzo Montali
- Department of Psychology, University of Milano-Bicocca, Milano, Italy
| | - Paula Castro
- Department of Social and Organizational Psychology, University Institute of Lisbon (ISCTE-IUL) and CIS-Iscte, Lisbon, Portugal
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Latchem-Hastings J, Latchem-Hastings G, Kitzinger J. Caring for People with Severe Brain Injuries: Improving Health Care Professional Communication and Practice Through Online Learning. THE JOURNAL OF CONTINUING EDUCATION IN THE HEALTH PROFESSIONS 2023; 43:267-273. [PMID: 36715702 PMCID: PMC10664780 DOI: 10.1097/ceh.0000000000000486] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/17/2022] [Accepted: 11/02/2022] [Indexed: 06/18/2023]
Abstract
INTRODUCTION Severe brain injuries can leave people in prolonged disorder of consciousness resulting in multifaceted medical, nursing, and rehabilitative needs that can be challenging for even the most experienced multidisciplinary team. The complexities of care, communication with families, and best interest decision-making about medical interventions means there is a need for ongoing training in clinical, social, ethical, and legal aspects. METHODS Using a combination of group discussions, interviews, and questionnaires with learners, this article reports an evaluation of designing and delivering an interprofessional, online work-based course to health care professionals caring for prolonged disorder of consciousness patients. RESULTS There were challenges for staff uptake because of COVID-19, but engaging with it increased knowledge in defining and diagnosing patients' conditions, understanding multidisciplinary team roles, communicating with families, and navigating legal and ethical issues. Course participation also enhanced critical and reflective thinking skills, provided a sense of connection to other professionals, and generated plans to improve service provision. DISCUSSION Online learning that enables health care professionals to engage at their own pace and also come together as an interprofessional community can provide invaluable continuing professional development and help to enhance joined up, holistic patient care. However, achieving this requires significant investment in creating research-led, multimedia, learning materials, and courses that include synchronous and asynchronous delivery to combine flexible study with the opportunity for peer networks to form. It also depends on a commitment from organizations to support staff online continuing professional development.
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Affiliation(s)
- Julie Latchem-Hastings
- Dr. J. Latchem-Hastings: Lecturer/HCRW Postdoctoral Fellow, School of Healthcare Sciences, College of Biomedical & Life Sciences, Cardiff University, Eastgate House, Cardiff, United Kingdom. Dr. G. Latchem-Hastings: Senior Lecturer, School of Healthcare Sciences, Cardiff University, Ty Dewi Sant, University Hospital of Wales, Heath Park, Cardiff, United Kingdom. Prof. Kitzinger: Professor of Communications, Journalism, Media and Cultural Studies, Cardiff University, Two Central Square, Central Square, Cardiff, United Kingdom
| | - Geraldine Latchem-Hastings
- Dr. J. Latchem-Hastings: Lecturer/HCRW Postdoctoral Fellow, School of Healthcare Sciences, College of Biomedical & Life Sciences, Cardiff University, Eastgate House, Cardiff, United Kingdom. Dr. G. Latchem-Hastings: Senior Lecturer, School of Healthcare Sciences, Cardiff University, Ty Dewi Sant, University Hospital of Wales, Heath Park, Cardiff, United Kingdom. Prof. Kitzinger: Professor of Communications, Journalism, Media and Cultural Studies, Cardiff University, Two Central Square, Central Square, Cardiff, United Kingdom
| | - Jenny Kitzinger
- Dr. J. Latchem-Hastings: Lecturer/HCRW Postdoctoral Fellow, School of Healthcare Sciences, College of Biomedical & Life Sciences, Cardiff University, Eastgate House, Cardiff, United Kingdom. Dr. G. Latchem-Hastings: Senior Lecturer, School of Healthcare Sciences, Cardiff University, Ty Dewi Sant, University Hospital of Wales, Heath Park, Cardiff, United Kingdom. Prof. Kitzinger: Professor of Communications, Journalism, Media and Cultural Studies, Cardiff University, Two Central Square, Central Square, Cardiff, United Kingdom
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Eilander HJ, van Erp WS, Driessen DMF, Overbeek BUH, Lavrijsen JCM. Post-Acute Level Of Consciousness scale revised (PALOC-sr): adaptation of a scale for classifying the level of consciousness in patients with a prolonged disorder of consciousness. BRAIN IMPAIR 2023; 24:341-346. [PMID: 38167183 DOI: 10.1017/brimp.2022.7] [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: 11/07/2022]
Abstract
OBJECTIVE To present an updated version of the 'Post-acute Level Of Consciousness scale' (PALOC-s), in accordance with the latest scientific insights. METHODS Within the context of a research project, 20 years ago, the PALOC-s was developed for the purpose of following the development of the level of consciousness of young unconscious patients participating in a rehabilitation program. Meanwhile, the understanding of the behavior related to different levels of consciousness has developed and terminology has changed, resulting in the need to revise the PALOC-s. With the preservation of the original description of the eight hierarchical levels of PALOC-s, adaptations are made in the terminology and grouping of these levels. RESULTS AND CONCLUSION This manuscript presents the revised version of PALOC-sr, which is suitable for use in clinical practice. The validation of this scale is recommended for its optimal use in future (international) research projects.
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Affiliation(s)
- Henk J Eilander
- Department of Elderly Care Medicine, Radboud Institute of Health Sciences, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Willemijn S van Erp
- Department of Elderly Care Medicine, Radboud Institute of Health Sciences, Radboud University Medical Center, Nijmegen, The Netherlands
- Accolade Zorg, Bosch en Duin, The Netherlands
- Libra Revalidatie & Audiologie, locatie Leijpark, Tilburg, The Netherlands
| | - Daniëlle M F Driessen
- Department of Elderly Care Medicine, Radboud Institute of Health Sciences, Radboud University Medical Center, Nijmegen, The Netherlands
- Libra Revalidatie & Audiologie, locatie Leijpark, Tilburg, The Netherlands
| | - Berno U H Overbeek
- Department of Elderly Care Medicine, Radboud Institute of Health Sciences, Radboud University Medical Center, Nijmegen, The Netherlands
- Azora, Terborg, The Netherlands
- Kalorama, Veste Brakkestein, Nijmegen, The Netherlands
| | - Jan C M Lavrijsen
- Department of Elderly Care Medicine, Radboud Institute of Health Sciences, Radboud University Medical Center, Nijmegen, The Netherlands
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Blond N, Andersen LM, Wæhrens EE, Høybye MT. Perspectives on consciousness in patients with disorders of consciousness from brain injury: group concept mapping study across clinic, research, and families. BMC Health Serv Res 2023; 23:471. [PMID: 37165429 PMCID: PMC10173477 DOI: 10.1186/s12913-023-09438-z] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2023] [Accepted: 04/24/2023] [Indexed: 05/12/2023] Open
Abstract
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.
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Affiliation(s)
- Niklas Blond
- Interacting Minds Centre, Department of Clinical Medicine, Aarhus University, Jens Chr. Skous Vej 4, Aarhus C, DK- 8000, Denmark
| | - Lise Marie Andersen
- Center for Elective Surgery, Silkeborg Regional Hospital, Silkeborg, Denmark
| | - Eva Elisabeth Wæhrens
- The Parker Institute, Copenhagen University Hospital Bispebjerg and Frederiksberg, Copenhagen, Denmark
- Occupational Science, Department of Public Health, User Perspectives and Community-based Interventions, University of Southern Denmark, Odense, Denmark
| | - Mette Terp Høybye
- Interacting Minds Centre, Department of Clinical Medicine, Aarhus University, Jens Chr. Skous Vej 4, Aarhus C, DK- 8000, Denmark.
- Center for Elective Surgery, Silkeborg Regional Hospital, Silkeborg, Denmark.
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Puppo C, Hansmann Y, Moinot L, Duval X, Chirouze C, Préau M. The social representations of diagnosing Lyme disease. PLoS One 2023; 18:e0276800. [PMID: 36757987 PMCID: PMC9910640 DOI: 10.1371/journal.pone.0276800] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2022] [Accepted: 10/13/2022] [Indexed: 02/10/2023] Open
Abstract
Social science studies on the controversy surrounding Lyme disease (LD) focused on the opposition between the "mainstream" and biomedical approach on one side and the "Lyme-literate" one on the other side, the latter claiming the existence of the chronic form of LD. The qualitative and exploratory study 'C18-48 Quali-Explo-PIQTIQ' (2019) investigated the social representations of LD in patients bitten by a tick. Twenty-four semi-structured interviews were conducted in three French medical units. Thematic and patient trajectory analyses were performed. Our results showed that, after the tick bite, some patients presented an "illness without disease" condition, characterised by uncertainty. In some cases, they consulted "Lyme-literate" health providers and received a diagnosis of chronic LD. This diagnosis was obtained by prescribing unassessed biological testing, providing an objective result and clinical categorisation. Unlike literature on the "Lyme-literate" approach, this diagnostic procedure involved some biomedical operations.
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Affiliation(s)
- C. Puppo
- UMR1296, Université Lyon 2, Lyon, France
| | | | - L. Moinot
- Univ. Bordeaux, ISPED, INSERM Bordeaux Population Health Research Center, UMR 1219, CIC1401-EC, CHU Bordeaux, Bordeaux, France
| | - X. Duval
- Hôpital Bichat-Claude Bernard, Paris, France
| | | | - M. Préau
- UMR1296, Université Lyon 2, Lyon, France
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Young M, Peterson AH. Neuroethics across the Disorders of Consciousness Care Continuum. Semin Neurol 2022; 42:375-392. [PMID: 35738293 DOI: 10.1055/a-1883-0701] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
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Gutin I. Not 'putting a name to it': Managing uncertainty in the diagnosis of childhood obesity. Soc Sci Med 2022; 294:114714. [PMID: 35032744 PMCID: PMC8821372 DOI: 10.1016/j.socscimed.2022.114714] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2021] [Revised: 12/23/2021] [Accepted: 01/08/2022] [Indexed: 02/03/2023]
Abstract
Childhood obesity is a challenging diagnosis. Children's body mass index (BMI) is an imprecise diagnostic of health, leading clinicians' interactions with patients and families to focus on the potential of future harm rather than the presence of infirmity or disease. This is complicated by emphasis on certainty in medical care; clinical diagnoses like childhood obesity are intended to help delineate good and bad health among patients. However, healthiness and wellbeing take on many meanings among individual children and families, especially in relation to weight. To better understand different forms of uncertainty and challenges in providing care, this study draws on 28 semi-structured interviews with U.S. health practitioners working with pediatric patients to examine strategies for communicating risk and defining success in the diagnosis and treatment of childhood obesity. Rather than focusing on patients' current BMIs or making the explicit diagnosis of obesity, clinicians turn to more optimistic prognoses emphasizing the gradual development of beliefs and behaviors that promote long-term physical, mental, and social health. This prognostic framework privileges the doctor-patient relationship over medical guidelines and protocols dictated by diagnoses, encouraging greater consideration of non-clinical factors shaping patients' health and weight. Clinicians expand their diagnostic framework and criteria to include information on the totality of patients' present and future lives, allowing for cognitively, emotionally, and socially attuned understanding of health and weight that is not focused on BMI. Critically, clinicians' awareness of the social etiology childhood obesity heightens their sense of futility about addressing it through clinical interventions, demonstrating the need for a diagnostic and treatment model that empowers doctors to look beyond the more proximate, biophysiological determinants of health.
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Affiliation(s)
- Iliya Gutin
- Population Research Center, University of Texas at Austin, 305 E. 23rd Street, Austin, TX, 78712-1699, USA.
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Pienaar K, Petersen A. Searching for diagnostic certainty, governing risk: Patients' ambivalent experiences of medical testing. SOCIOLOGY OF HEALTH & ILLNESS 2022; 44:25-40. [PMID: 34713910 PMCID: PMC9298388 DOI: 10.1111/1467-9566.13391] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/03/2021] [Revised: 09/30/2021] [Accepted: 10/04/2021] [Indexed: 05/13/2023]
Abstract
Diagnosis is pivotal to medicine's epistemic system: it serves to explain individual symptoms, classify them into recognizable conditions and determine their prognosis and treatment. Medical tests, or investigative procedures for detecting and monitoring disease, play a central role in diagnosis. While testing promises diagnostic certainty or a definitive risk assessment, it often produces uncertainties and new questions which call for yet further tests. In short, testing, regardless of its specific application, is imbued with meaning and emotionally fraught. In this article, we explore individuals' ambivalent experiences of testing as they search for diagnostic certainty, and the anxieties and frustrations of those for whom it remains elusive. Combining insights from sociological work on ambivalence and the biopolitics of health, and drawing on qualitative interviews with Australian healthcare recipients who have undergone testing in the context of clinical practice, we argue that these experiences are explicable in light of the contradictory impulses and tensions associated with what we term 'bio-subjectification'. We consider the implications of our analysis in light of the development of new tests that produce ever finer delineations between healthy and diseased populations, concluding that their use will likely multiply uncertainties and heighten rather than lessen anxieties.
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Affiliation(s)
- Kiran Pienaar
- Sociology DepartmentSchool of Social Sciences and HumanitiesDeakin UniversityGeelongVic.Australia
- Sociology ProgramSchool of Social SciencesMonash UniversityClaytonVic.Australia
| | - Alan Petersen
- Sociology ProgramSchool of Social SciencesMonash UniversityClaytonVic.Australia
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Zulato E, Montali L, Bauer MW. Understanding a liminal condition: Comparing emerging representations of the “vegetative state”. EUROPEAN JOURNAL OF SOCIAL PSYCHOLOGY 2021. [DOI: 10.1002/ejsp.2794] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Affiliation(s)
- Edoardo Zulato
- Department of Psychology University of Milano‐Bicocca Milano Italy
| | - Lorenzo Montali
- Department of Psychology University of Milano‐Bicocca Milano Italy
| | - Martin W. Bauer
- Department of Psychological and Behavioural Science London School of Economics and Political Science (LSE) London UK
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Jutel A. Uncertainty and the inconvenient facts of diagnosis. ENDEAVOUR 2021; 45:100764. [PMID: 33812275 DOI: 10.1016/j.endeavour.2021.100764] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/09/2020] [Revised: 01/08/2021] [Accepted: 03/19/2021] [Indexed: 06/12/2023]
Abstract
One common contemporary usage of the term "diagnostic uncertainty" is to refer to cases for which a diagnosis is not, or cannot, be applied to the presenting case. This is a paradoxical usage, as the absence of diagnosis is often as close to a certainty as can be a human judgement. What makes this sociologically interesting is that it represents an "epistemic defence," or a means of accounting for a failure of medicine's explanatory system. This system is based on diagnosis, or the classification of individual complaints into recognizable diagnostic categories. Diagnosis is pivotal to medicine's epistemic setting, for it purports to explain illness via diagnosis, and yet is not always able to do so. This essay reviews this paradoxical use, and juxtaposes it to historical explanations for non-diagnosable illnesses. It demonstrates how representing non-diagnosis as uncertainty protects the epistemic setting by positioning the failure to locate a diagnosis in the individual, rather than in the medical paradigm.
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Affiliation(s)
- Annemarie Jutel
- Te Herenga Waka-Victoria University of Wellington, Kelburn Pde, Wellington, 6140, New Zealand.
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Pienaar K, Petersen A, Bowman DM. Managing risks or generating uncertainties? Ambiguous ontologies of testing in Australian healthcare. Health (London) 2020; 25:669-687. [PMID: 32186208 DOI: 10.1177/1363459320912830] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Medical testing promises to establish certainty by providing a definitive assessment of risk or diagnosis. But can those who rely on tests to offer advice or make clinical decisions be assured of this certainty? This article examines how Australian health professionals, namely clinicians, microbiologists, specialist physicians and health policymakers, delineate the boundary between certainty and uncertainty in their accounts of medical testing. Applying concepts from science and technology studies, and drawing on qualitative data from a sociological study of testing in Australian healthcare, we consider how professionals ascribe meaning to testing and test results. As we argue, for these health professionals, the 'evidence' that testing generates has ambiguous ontological significance: while it promises to provide diagnostic certainty and clear direction for advice or treatment, it also generates uncertainties that may lead to yet further tests. Our analysis leads us to question a key premise of testing, namely that it is possible to establish certainty in medical practice via the measurement of individual health risks and disease markers. Against this dominant view, the responses of the health professionals in our study suggest that uncertainty is intrinsic to testing due to the constantly changing, unstable character of 'evidence'. We conclude by considering the implications of our analysis in light of healthcare's increasing reliance on sophisticated technologies of 'personalised' testing using genetic information and data analytics.
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Huxtable R. Dying too soon or living too long? Withdrawing treatment from patients with prolonged disorders of consciousness after Re Y. BMC Med Ethics 2019; 20:91. [PMID: 31884958 PMCID: PMC6936052 DOI: 10.1186/s12910-019-0424-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2019] [Accepted: 11/07/2019] [Indexed: 12/22/2022] Open
Abstract
BACKGROUND In the ruling in Y [2018], the UK Supreme Court has confirmed that there is no general requirement for the courts in England and Wales to authorise the withdrawal of clinically assisted nutrition and hydration from patients with prolonged disorders of consciousness. The perceived requirement, which originated in a court ruling in 1993, encompassed those in the vegetative state and those in the minimally conscious state. The ruling in Y confirms that the court may still be approached to decide difficult or contested cases, but there is otherwise no routine requirement that the judges be approached. MAIN BODY There is much to welcome in this ruling, particularly as it means that these decisions for these patients are no longer (unusually) singled out for a judicial decision, with all the financial and emotional costs that court proceedings can entail. However, there is also a risk that the ruling might have unwelcome consequences. First, there is the possibility that patients might die too soon, particularly if doctors should now adopt the courts' previous reasoning, which has suggested that patients in the vegetative state lack interests, so treatment may - perhaps must - be withdrawn. Secondly, there is the converse possibility that patients might live too long, since empirical research suggests that - whether intentionally or not - patients' families, clinicians, and the health system appear to promote treatment-by-default. CONCLUSION Rather than adopt general positions, which may be contestable and potentially risky, this article argues, on a pluralistic basis, that the individual patient should be the focus of any decision made in his or her 'best interests'. The existing legal framework in England and Wales, which is provided by the Mental Capacity Act 2005, already points in this direction, although more efforts may be needed to ensure that those involved in making these decisions are suitably educated and supported. Fortunately, new guidance from the British Medical Association could help clinicians and families to make decisions in the future, which are appropriate for the incapacitated individual patient in question.
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Affiliation(s)
- Richard Huxtable
- Centre for Ethics in Medicine, Population Health Sciences, Bristol Medical School, Canynge Hall, 39 Whatley Road, Bristol, BS8 2PS, UK.
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14
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Heritage J, McArthur A. The diagnostic moment: A study in US primary care. Soc Sci Med 2019; 228:262-271. [DOI: 10.1016/j.socscimed.2019.03.022] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2018] [Revised: 03/08/2019] [Accepted: 03/12/2019] [Indexed: 10/27/2022]
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15
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Boulton T. Nothing and Everything: Fibromyalgia as a Diagnosis of Exclusion and Inclusion. QUALITATIVE HEALTH RESEARCH 2019; 29:809-819. [PMID: 30296924 DOI: 10.1177/1049732318804509] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/08/2023]
Abstract
The diagnostic process promises a label that validates patients' embodied experiences and a road map for living with and treating illness. Drawing on 31 qualitative interviews with women and men in Canada and the United Kingdom who have been diagnosed with fibromyalgia (FM), in this article, I examine the participants' experiences of the diagnostic process and how they feel about receiving this label. The interviews reflect that the FM label is plagued by uncertainty because the diagnosis is based on the absence of verifiable pathology. The respondents' narratives also reveal that FM is a vague diagnosis that includes a multitude of symptoms, overlaps with several other diagnoses, and results in feelings of doubt regarding whether it is the correct label. Thus, the participants' narratives reflect that the FM diagnosis is largely an empty promise because it fails to provide definitive answers or confer meaning and legitimacy to their illness experiences.
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Blain-Moraes S, Racine E, Mashour GA. Consciousness and Personhood in Medical Care. Front Hum Neurosci 2018; 12:306. [PMID: 30116185 PMCID: PMC6082939 DOI: 10.3389/fnhum.2018.00306] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2018] [Accepted: 07/16/2018] [Indexed: 11/25/2022] Open
Abstract
Current paradigms in Western medicine often fail to differentiate clearly between consciousness, responsiveness and personhood. The growing number of individuals who exist with sustainable cardiopulmonary systems but who are behaviorally unresponsive has prompted a cultural reconsideration of the relationship between the presence of consciousness and what it means to be a person. This article presents relevant clinical situations that exemplify the different modes in which personhood and consciousness can be associated and dissociated: disorders of consciousness, emergence from anesthesia, and neocortical death. We draw from these examples to call for a reflection on and possible revision of the dominant approach towards unresponsive persons to one in which care providers may work from the default assumption of the existence of an individual’s personhood as part of their therapeutic intervention. Behavior consistent with this assumption aligns with the principle of respect for persons in the face of the uncertainty created by the high rate of misdiagnosis of unconsciousness in unresponsive patients and is most consistent with a therapeutic approach to care considering evidence suggesting that attributing personhood may in fact evoke consciousness in these patients.
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Affiliation(s)
- Stefanie Blain-Moraes
- School of Physical and Occupational Therapy, McGill University, Montreal, QC, Canada
| | - Eric Racine
- Institut de Recherches Cliniques de Montréal, Montreal, QC, Canada
| | - George A Mashour
- Department of Anesthesiology, Center for Consciousness Science, University of Michigan Medical School, Ann Arbor, MI, United States
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Underwood J, Rhodes C. A qualitative investigation of hospital visitors' experiences using the analytic lens of liminality: Informing nursing practice and policy. Nurs Inq 2018; 25:e12239. [PMID: 29790231 DOI: 10.1111/nin.12239] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/06/2018] [Indexed: 11/28/2022]
Abstract
This research aimed to inform nursing practice and policy by identifying satisfying and problematic experiences of hospital visitors during the hospitalisation episode of a significant other. An extensive contextual review revealed that healthcare systems in advanced economies face multiple pressures and that in England, the government leaves the determination of hospital visiting rules to individual trusts. The analytic lens of liminality provides rich interpretations of visitors' accounts and demonstrates the importance to visitors of structure (hospital rules and systems) and communitas (social bonding among liminal personae). Supportive hospital structures reduce the challenges of liminality and increase satisfaction. The data further suggest an extension to current understandings of liminality. Strong structure and successful communitas permit a safe exit from liminality after the hospitalisation episode for visitors with a close emotional bond with the patient.
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Affiliation(s)
- Janet Underwood
- School of Human and Health Sciences, University of Huddersfield, Huddersfield, UK
| | - Christine Rhodes
- School of Human and Health Sciences, University of Huddersfield, Huddersfield, UK
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18
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Rasmussen EB. Balancing medical accuracy and diagnostic consequences: diagnosing medically unexplained symptoms in primary care. SOCIOLOGY OF HEALTH & ILLNESS 2017; 39:1227-1241. [PMID: 28523700 DOI: 10.1111/1467-9566.12581] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/07/2023]
Abstract
Focusing on the case of medically unexplained symptoms (MUS), this article explores diagnostic classification in the absence of biomedical evidence or other strong medical warrants for diagnosis. The data are from three focus group interviews with Norwegian general practitioners (GPs) conducted in 2015, that centred on the issue of what diagnoses to use (or not) for MUS. The qualitative analysis reconstructs the logic underlying GPs' diagnostic accounts, which centred on the meaning of diagnostic categories and on anticipating how 'generalised others' would respond to those meanings (called 'diagnosing by anticipation'). The analysis suggests that GPs confer diagnoses by balancing unwarranted medical accuracy and anticipated harmful diagnostic consequences; the goal of diagnosis was finding categories in the International Classification of Primary Care that would yield acceptable results, without making a liar of the GP in the process. Drawing on the distinction between diagnosis as colligation and classification, the findings and their relevance for medical sociology are discussed. Counter to frequent descriptions as 'illness that cannot be diagnosed', the analysis shows how GPs can diagnose MUS in the bureaucratic sense of diagnosis as classification - a sense that has been missing from sociological view.
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Affiliation(s)
- Erik B Rasmussen
- Centre for the study of professions, Oslo and Akershus University College of Applied Sciences, Oslo, Norway
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19
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Holland S. Commentary on Derick Wade's 'Back to the bedside? Making clinical decisions in patients with prolonged unconsciousness' and Zoe Fritz' 'Can 'Best Interests' derail the trolley?' Examining withdrawal of clinically assisted nutrition and hydration in patients in the permanent vegetative state. JOURNAL OF MEDICAL ETHICS 2017; 43:455-456. [PMID: 27582079 DOI: 10.1136/medethics-2016-103739] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/05/2016] [Accepted: 08/14/2016] [Indexed: 06/06/2023]
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Kitzinger J, Kitzinger C, Cowley J. When 'Sanctity of Life' and 'Self-Determination' clash: Briggs versus Briggs [2016] EWCOP 53 - implications for policy and practice. JOURNAL OF MEDICAL ETHICS 2017; 43:446-449. [PMID: 28642353 PMCID: PMC5520012 DOI: 10.1136/medethics-2016-104118] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/26/2016] [Revised: 05/07/2017] [Accepted: 05/16/2017] [Indexed: 05/30/2023]
Abstract
In a landmark judgment in the English Court of Protection, the judge (Charles J) found it to be in the best interests of a minimally conscious patient for clinically assisted nutrition and hydration (CANH) to be withdrawn, with the inevitable consequence that the patient would die. In making this judgment, it was accepted that the patient's level of consciousness - if CANH were continued and rehabilitation provided - might improve, and that he might become capable of expressing emotions and making simple choices. The decision to withdraw treatment relied on a best interests decision, which gave great weight to the patient's past wishes, feelings, values and beliefs, and brought a 'holistic' approach to understanding what this particular patient would have wanted. We draw on our own experience of supporting families, advocating for patients and training healthcare professionals in similar situations to consider the implications of the published judgment for policy and practice with patients in prolonged disorders of consciousness and their families.
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Affiliation(s)
- Jenny Kitzinger
- School of Journalism, Media and Cultural Studies, Cardiff University, Cardiff, UK
| | | | - Jakki Cowley
- Empowerment Matters, Liscard Business Centre, The Old School, Liscard, UK
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21
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Kitzinger J, Kitzinger C. Causes and consequences of delays in treatment-withdrawal from PVS patients: a case study of Cumbria NHS Clinical Commissioning Group v Miss S and Ors [2016] EWCOP 32. JOURNAL OF MEDICAL ETHICS 2017; 43:459-468. [PMID: 27663784 PMCID: PMC5520014 DOI: 10.1136/medethics-2016-103853] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/31/2016] [Revised: 09/08/2016] [Accepted: 09/16/2016] [Indexed: 05/25/2023]
Abstract
Life-extending treatment, in the form of artificial nutrition and hydration, is often provided to people in permanent vegetative states (PVS) in England and Wales for many years, even when their family believes the patient would not want it and despite the fact that no court in the UK has ever found in favour of continuing such treatment for a patient with a confirmed PVS diagnosis. The first half of this article presents a close analysis of the recent case of Cumbria NHS Clinical Commissioning Group v Miss S and Ors [2016] EWCOP 32. It examines the causes of delay in bringing this case to court and reaching a final judgment. It draws not only on the published judgment, but also on the two authors' involvement in supporting the family (before, during and subsequent to the court hearings) as a result of their academic and policy-related work in this area. This includes conversations with the family and with members of the clinical and legal teams, and observations in court. The second part of the article draws out the ethical and practical implications of the findings for theory and policy and suggests ways forward in relation to (a) the provision and inspection of care for these patients; (b) legal practice in relation to 'best interests' and (c) the perceived requirement under English law for a court application before life-prolonging treatment can be withdrawn from PVS patients-even in the absence of any 'in principle' opposition.
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Affiliation(s)
- Jenny Kitzinger
- School of Journalism, Media and Cultural Studies, Cardiff University, Cardiff, UK
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22
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Chandler JA, Sun JA, Racine E. Online public reactions to fMRI communication with patients with disorders of consciousness: Quality of life, end-of-life decision making, and concerns with misdiagnosis. AJOB Empir Bioeth 2017; 8:40-51. [PMID: 28949872 DOI: 10.1080/23294515.2016.1226199] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/07/2023]
Abstract
BACKGROUND Recently, the news media have reported on the discovery of covert awareness and the establishment of limited communication using a functional magnetic resonance imaging (fMRI) neuroimaging technique with several brain-injured patients thought to have been in a vegetative state. This discovery has raised many ethical, legal, and social questions related to quality of life, end-of-life decision making, diagnostic and prognostic accuracy in disorders of consciousness, resource allocation, and other issues. This project inquires into the public responses to these discoveries. METHODS We conducted a thematic analysis of online comments (n = 779) posted in response to 15 news articles and blog posts regarding the case of a Canadian patient diagnosed for 12 years as in a vegetative state, but who was reported in 2012 as having been able to communicate via fMRI. The online comments were coded using an iteratively refined codebook structured around 14 main themes. RESULTS Among the most frequent public reactions revealed in the online comments were discussions of the quality of life of patients with disorders of consciousness, whether life-sustaining treatment should be withdrawn (and whether the fMRI communication technique should be used to ask patients about this), and misgivings about the accuracy of diagnosis in disorders of consciousness and brain death. CONCLUSIONS These public perspectives are relevant to the obligations of clinicians, lawyers, and public policymakers to patients, families, and the public. Future work should consider how best to alleviate families' concerns as this type of research shakes their faith in diagnostic accuracy, to clarify the legal rules relating to advance directives in this context, and to address the manner in which public messaging might help to alleviate any indirect impact on confidence in the organ donation system.
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Affiliation(s)
| | | | - Eric Racine
- b Institut de Recherches Cliniques de Montreal (IRCM) , Neuroethics Research Unit
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Latchem J, Kitzinger J, Kitzinger C. Physiotherapy for vegetative and minimally conscious state patients: family perceptions and experiences. Disabil Rehabil 2015; 38:22-9. [PMID: 25669235 PMCID: PMC4696242 DOI: 10.3109/09638288.2015.1005759] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2014] [Revised: 01/03/2015] [Accepted: 01/06/2015] [Indexed: 12/02/2022]
Abstract
PURPOSE To examine family perceptions of physiotherapy provided to relatives in vegetative or minimally conscious states. METHOD Secondary thematic analysis of 65 in-depth narrative interviews with family members of people in vegetative or minimally conscious states. RESULTS Families place great significance on physiotherapy in relation to six dimensions: "Caring for the person", "Maximising comfort", "Helping maintain health/life", "Facilitating progress", "Identifying or stimulating consciousness" and "Indicating potential for meaningful recovery". They can have high expectations of what physiotherapy may deliver but also, at times, express concerns about physiotherapy's potential to cause pain or distress, or even constitute a form of torture if they believe there is no hope for "meaningful" recovery. CONCLUSION Physiotherapists can make an important contribution to supporting this patient group and their families but it is vital to recognise that family understandings of physiotherapy may differ significantly from those of physiotherapists. Both the delivery and the withdrawal of physiotherapy is highly symbolic and can convey (inadvertent) messages to people about their relative's current and future state. A genuine two-way dialogue between practitioners and families about the aims of physiotherapeutic interventions, potential outcomes and patients' best interests is critical to providing a good service and establishing positive relationships and appropriate treatment. IMPLICATIONS FOR REHABILITATION Families of people in PVS or MCS consider physiotherapy as a vital part of good care. Clear communication is critical if therapeutic input is withdrawn or reduced. The purpose of physiotherapy interventions can be misinterpreted by family members. Physiotherapists need to clarify what physiotherapy can, and cannot, achieve. Families can find some interventions distressing to witness--explaining to families what interventions involve, what they can expect to see (and hear) may be helpful. Physiotherapists and families can attribute different meanings to physiotherapy. Physiotherapists need to identify how families view interventions and modify their explanations accordingly to enhance information sharing.
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Affiliation(s)
- Julie Latchem
- School of Social Sciences, Cardiff University,
Cardiff,
UK
| | - Jenny Kitzinger
- School of Journalism, Media and Cultural Studies, Cardiff University,
Cardiff,
UK
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Vogl J, Heine AM, Steinhoff N, Weiss K, Tucek G. Neuroscientific and neuroanthropological perspectives in music therapy research and practice with patients with disorders of consciousness. Front Neurosci 2015; 9:273. [PMID: 26300720 PMCID: PMC4523786 DOI: 10.3389/fnins.2015.00273] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2015] [Accepted: 07/17/2015] [Indexed: 11/13/2022] Open
Abstract
A growing understanding of music therapy with patients with disorders of consciousness (DOC) has developed from observing behavioral changes and using these to gain new ways of experiencing this research environment and setting. Neuroscience provides further insight into the effects of music therapy; however, various studies with similar protocols show different results. The neuroanthropological approach is informed by anthropological and philosophical frameworks. It puts emphasis on a research with and not just on human beings concerning the subject/object question within a research process. It examines relational aspects and outcomes in the context of working in an interdisciplinary team. This allows a broader view of music therapy in a reflective process and leads to a careful interpretation of behavioral reactions and imaging results. This article discusses the importance of the neuroanthropological perspective on our way of obtaining knowledge and its influence on therapeutic practice. It is important to consider how knowledge is generated as it influences the results. Data from two cases will be presented to illustrate the neuroanthropological approach by comparing quantitative PET data with qualitative results of video analyses.
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Affiliation(s)
- Julia Vogl
- Department of Social and Cultural Anthropology, University of Vienna Vienna, Austria
| | - Astrid M Heine
- Department of Music Therapy, IMC University of Applied Sciences Krems, Austria
| | - Nikolaus Steinhoff
- OptimaMed Neurological Rehabilitation Kittsee, Austria ; Department of Neurology, Regional Hospital Hochegg Grimmenstein, Austria
| | - Konrad Weiss
- Department of Nuclear Medicine, Regional Hospital Wiener Neustadt Wiener Neustadt, Austria
| | - Gerhard Tucek
- Department of Music Therapy, IMC University of Applied Sciences Krems, Austria
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25
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Liberati G, Hünefeldt T, Olivetti Belardinelli M. Questioning the dichotomy between vegetative state and minimally conscious state: a review of the statistical evidence. Front Hum Neurosci 2014; 8:865. [PMID: 25404905 PMCID: PMC4217390 DOI: 10.3389/fnhum.2014.00865] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2014] [Accepted: 10/07/2014] [Indexed: 01/24/2023] Open
Abstract
Given the enormous consequences that the diagnosis of vegetative state (VS) vs. minimally conscious state (MCS) may have for the treatment of patients with disorders of consciousness, it is particularly important to empirically legitimate the distinction between these two discrete levels of consciousness. Therefore, the aim of this contribution is to review all the articles reporting statistical evidence concerning the performance of patients in VS vs. patients in MCS, on behavioral or neurophysiological measures. Twenty-three articles matched these inclusion criteria, and comprised behavioral, electroencephalographic (EEG), positron emission tomography (PET) and magnetic resonance imaging (MRI) measures. The analysis of these articles yielded 47 different statistical findings. More than half of these findings (n = 24) did not reveal any statistically significant difference between VS and MCS. Overall, there was no combination of variables that allowed reliably discriminating between VS and MCS. This pattern of results casts doubt on the empirical validity of the distinction between VS and MCS.
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Affiliation(s)
- Giulia Liberati
- Institute of Neuroscience, Université Catholique de Louvain Brussels, Belgium
| | - Thomas Hünefeldt
- ECONA - Interuniversity Centre for Research on Cognitive Processing in Natural and Artificial Systems, "Sapienza" University of Rome Rome, Italy ; Department of Philosophy, Catholic University of Eichstätt-Ingolstadt Eichstätt, Germany
| | - Marta Olivetti Belardinelli
- ECONA - Interuniversity Centre for Research on Cognitive Processing in Natural and Artificial Systems, "Sapienza" University of Rome Rome, Italy ; Department of Psychology, Sapienza, University of Rome Rome, Italy
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