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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 2024:10.1007/s12028-024-02012-3. [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] [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, Kazazian K, Fischer D, Lissak IA, Bodien YG, Edlow BL. Disclosing Results of Tests for Covert Consciousness: A Framework for Ethical Translation. Neurocrit Care 2024; 40:865-878. [PMID: 38243150 PMCID: PMC11147696 DOI: 10.1007/s12028-023-01899-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2023] [Accepted: 11/22/2023] [Indexed: 01/21/2024]
Abstract
The advent of neurotechnologies including advanced functional magnetic resonance imaging and electroencephalography to detect states of awareness not detectable by traditional bedside neurobehavioral techniques (i.e., covert consciousness) promises to transform neuroscience research and clinical practice for patients with brain injury. As these interventions progress from research tools into actionable, guideline-endorsed clinical tests, ethical guidance for clinicians on how to responsibly communicate the sensitive results they yield is crucial yet remains underdeveloped. Drawing on insights from empirical and theoretical neuroethics research and our clinical experience with advanced neurotechnologies to detect consciousness in behaviorally unresponsive patients, we critically evaluate ethical promises and perils associated with disclosing the results of clinical covert consciousness assessments and describe a semistructured approach to responsible data sharing to mitigate potential risks.
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Affiliation(s)
- Michael J Young
- Center for Neurotechnology and Neurorecovery, Department of Neurology, Massachusetts General Hospital and Harvard Medical School, 101 Merrimac Street, Suite 310, Boston, MA, 02114, USA.
| | - Karnig Kazazian
- Center for Neurotechnology and Neurorecovery, Department of Neurology, Massachusetts General Hospital and Harvard Medical School, 101 Merrimac Street, Suite 310, Boston, MA, 02114, USA
- Western Institute of Neuroscience, Western University, London, ON, Canada
| | - David Fischer
- University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | - India A Lissak
- Center for Neurotechnology and Neurorecovery, Department of Neurology, Massachusetts General Hospital and Harvard Medical School, 101 Merrimac Street, Suite 310, Boston, MA, 02114, USA
| | - Yelena G Bodien
- Center for Neurotechnology and Neurorecovery, Department of Neurology, Massachusetts General Hospital and Harvard Medical School, 101 Merrimac Street, Suite 310, Boston, MA, 02114, USA
| | - Brian L Edlow
- Center for Neurotechnology and Neurorecovery, Department of Neurology, Massachusetts General Hospital and Harvard Medical School, 101 Merrimac Street, Suite 310, Boston, MA, 02114, USA
- Athinoula A. Martinos Center for Biomedical Imaging, Massachusetts General Hospital and Harvard Medical School, Charlestown, MA, USA
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Young MJ, Awad A, Andreev A, Bonkhoff AK, Schirmer MD, Dmytriw AA, Vranic JE, Rabinov JD, Doron O, Stapleton CJ, Das AS, Edlow BL, Singhal AB, Rost NS, Patel AB, Regenhardt RW. Characterizing coma in large vessel occlusion stroke. J Neurol 2024; 271:2658-2661. [PMID: 38366071 DOI: 10.1007/s00415-024-12199-2] [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: 11/30/2023] [Revised: 01/07/2024] [Accepted: 01/14/2024] [Indexed: 02/18/2024]
Abstract
BACKGROUND Coma is an unresponsive state of disordered consciousness characterized by impaired arousal and awareness. The epidemiology and pathophysiology of coma in ischemic stroke has been underexplored. We sought to characterize the incidence and clinical features of coma as a presentation of large vessel occlusion (LVO) stroke. METHODS Individuals who presented with LVO were retrospectively identified from July 2018 to December 2020. Coma was defined as an unresponsive state of impaired arousal and awareness, operationalized as a score of 3 on NIHSS item 1a. RESULTS 28/637 (4.4%) patients with LVO stroke were identified as presenting with coma. The median NIHSS was 32 (IQR 29-34) for those with coma versus 11 (5-18) for those without (p < 0.0001). In coma, occlusion locations included basilar (13), vertebral (2), internal carotid (5), and middle cerebral (9) arteries. 8/28 were treated with endovascular thrombectomy (EVT), and 20/28 died during the admission. 65% of patients not treated with EVT had delayed presentations or large established infarcts. In models accounting for pre-stroke mRS, basilar occlusion location, intravenous thrombolysis, and EVT, coma independently increased the odds of transitioning to comfort care during admission (aOR 6.75; 95% CI 2.87,15.84; p < 0.001) and decreased the odds of 90-day mRS 0-2 (aOR 0.12; 95% CI 0.03,0.55; p = 0.007). CONCLUSIONS It is not uncommon for patients with LVO to present with coma, and delayed recognition of LVO can lead to poor outcomes, emphasizing the need for maintaining a high index of suspicion. While more commonly thought to result from posterior LVO, coma in our cohort was similarly likely to result from anterior LVO. Efforts to improve early diagnosis and care of patients with LVO presenting with coma are crucial.
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Affiliation(s)
- Michael J Young
- Department of Neurology, Massachusetts General Hospital and Harvard Medical School, 101 Merrimac Street, Suite 310, Boston, MA, 02114, USA.
| | - Amine Awad
- Department of Neurology, Massachusetts General Hospital and Harvard Medical School, 101 Merrimac Street, Suite 310, Boston, MA, 02114, USA
| | - Alexander Andreev
- Department of Neurology, Beth Israel Deaconess Medical Center, Boston, MA, USA
| | - Anna K Bonkhoff
- Department of Neurology, Massachusetts General Hospital and Harvard Medical School, 101 Merrimac Street, Suite 310, Boston, MA, 02114, USA
| | - Markus D Schirmer
- Department of Neurology, Massachusetts General Hospital and Harvard Medical School, 101 Merrimac Street, Suite 310, Boston, MA, 02114, USA
| | - Adam A Dmytriw
- Department of Neurosurgery, Massachusetts General Hospital and Harvard Medical School, Boston, USA
- Department of Radiology, Massachusetts General Hospital and Harvard Medical School, Boston, USA
| | - Justin E Vranic
- Department of Neurosurgery, Massachusetts General Hospital and Harvard Medical School, Boston, USA
- Department of Radiology, Massachusetts General Hospital and Harvard Medical School, Boston, USA
| | - James D Rabinov
- Department of Neurosurgery, Massachusetts General Hospital and Harvard Medical School, Boston, USA
- Department of Radiology, Massachusetts General Hospital and Harvard Medical School, Boston, USA
| | - Omer Doron
- Department of Neurosurgery, Massachusetts General Hospital and Harvard Medical School, Boston, USA
| | - Christopher J Stapleton
- Department of Neurosurgery, Massachusetts General Hospital and Harvard Medical School, Boston, USA
| | - Alvin S Das
- Department of Neurology, Massachusetts General Hospital and Harvard Medical School, 101 Merrimac Street, Suite 310, Boston, MA, 02114, USA
- Department of Neurology, Beth Israel Deaconess Medical Center, Boston, MA, USA
| | - Brian L Edlow
- Department of Neurology, Massachusetts General Hospital and Harvard Medical School, 101 Merrimac Street, Suite 310, Boston, MA, 02114, USA
| | - Aneesh B Singhal
- Department of Neurology, Massachusetts General Hospital and Harvard Medical School, 101 Merrimac Street, Suite 310, Boston, MA, 02114, USA
| | - Natalia S Rost
- Department of Neurology, Massachusetts General Hospital and Harvard Medical School, 101 Merrimac Street, Suite 310, Boston, MA, 02114, USA
| | - Aman B Patel
- Department of Neurosurgery, Massachusetts General Hospital and Harvard Medical School, Boston, USA
| | - Robert W Regenhardt
- Department of Neurology, Massachusetts General Hospital and Harvard Medical School, 101 Merrimac Street, Suite 310, Boston, MA, 02114, USA
- Department of Neurosurgery, Massachusetts General Hospital and Harvard Medical School, Boston, USA
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Edlow BL, Claassen J, Suarez JI. Common data elements for disorders of consciousness. Neurocrit Care 2024; 40:715-717. [PMID: 38291278 DOI: 10.1007/s12028-023-01931-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2024]
Affiliation(s)
- Brian L Edlow
- Center for Neurotechnology and Neurorecovery, Department of Neurology, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA.
- Athinoula A. Martinos Center for Biomedical Imaging, Massachusetts General Hospital, Charlestown, MA, USA.
| | - Jan Claassen
- Department of Neurology, Columbia University Medical Center, New York, NY, USA
- NewYork-Presbyterian Hospital, New York, NY, USA
| | - Jose I Suarez
- Division of Neurosciences Critical Care, Departments of Neurology, Neurosurgery, and Anesthesiology and Critical Care Medicine, The Johns Hopkins University and The Johns Hopkins Hospital, Baltimore, MD, USA
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