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Murtaugh B, Fager S, Sorenson T. Emergence from Disorders of Consciousness: Optimizing Self-Agency Through Communication. Phys Med Rehabil Clin N Am 2024; 35:175-191. [PMID: 37993188 PMCID: PMC11216683 DOI: 10.1016/j.pmr.2023.07.002] [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] [Indexed: 11/24/2023]
Abstract
Language and communication deficits are intrinsic to disorders of consciousness. This article will provide an overview of language and communication deficits that can significantly confound the accuracy of diagnostic assessment in these patients. Authors will also discuss interventions to promote early communication using assistive technology and augmentative communication rehabilitation strategies. Finally, this article will discuss the importance of family education as well as ethical considerations connected to the recovery of communication and adaptive strategies to support patient autonomy and enhance self-agency.
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Affiliation(s)
- Brooke Murtaugh
- Department of Rehabilitation Programs, Madonna Rehabilitation Hospitals, 5401 South Street, Lincoln, NE 68506, USA.
| | - Susan Fager
- Research Institute, Madonna Rehabilitation Hospitals, 5401 South Street, Lincoln, NE 68506, USA
| | - Tabatha Sorenson
- Department of Occupational Therapy, Madonna Rehabilitation Hospitals, 5401 South Street, Lincoln, NE 68506, USA
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Manevich A, Yehene E, Rubin SS. A case for inclusion of disordered Non-Death Interpersonal Grief as an official diagnosis: rationale, challenges and opportunities. Front Psychiatry 2023; 14:1300565. [PMID: 38161721 PMCID: PMC10757611 DOI: 10.3389/fpsyt.2023.1300565] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/23/2023] [Accepted: 11/28/2023] [Indexed: 01/03/2024] Open
Affiliation(s)
- Alexander Manevich
- Department of Psychology, Kinneret Academic College, Tzemach, Israel
- Department of Behavioral Sciences, Kinneret Academic College, Tzemach, Israel
- International Laboratory for the Study of Loss, Bereavement and Human Resilience and the School of Psychological Sciences, University of Haifa, Haifa, Israel
| | - Einat Yehene
- School of Behavioral Sciences, Academic College Tel Aviv-Yaffo, Tel Aviv, Israel
| | - Simon Shimshon Rubin
- International Laboratory for the Study of Loss, Bereavement and Human Resilience and the School of Psychological Sciences, University of Haifa, Haifa, Israel
- Department of Psychology, Max Stern Academic College of Emek Yezreel, Jezreel Valley, Israel
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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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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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Yehene E, Manevich A, Rubin SS. Caregivers' Grief in Acquired Non-death Interpersonal Loss (NoDIL): A Process Based Model With Implications for Theory, Research, and Intervention. Front Psychol 2021; 12:676536. [PMID: 33995234 PMCID: PMC8119762 DOI: 10.3389/fpsyg.2021.676536] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2021] [Accepted: 04/07/2021] [Indexed: 12/31/2022] Open
Abstract
The number of family members caring and caregiving for a loved one undergoing physical and mental changes continues to increase dramatically. For many, this ongoing experience not only involves the “burden of caregiving” but also the “burden of grief” as their loved-one’s newfound medical condition can result in the loss of the person they previously knew. Dramatic cognitive, behavioral, and personality changes, often leave caregivers bereft of the significant relationship they shared with the affected person prior to the illness or injury. This results in what we term conditions of acquired “non-death interpersonal loss” (NoDIL). Current approaches to these losses use an amalgam of models drawn from both death and non-death loss. Despite their utility, these frameworks have not adequately addressed the unique processes occurring in the interpersonal sphere where the grieving caregiver needs to reach some modus vivendi regarding the triad of “who the person was,” “who they are now,” and “who they will yet become.” In this paper we propose a process-based model which addresses cognitive-emotional-behavioral challenges caregivers meet in the face of their new reality. These require a revision of the interpersonal schemas and the relationships that takes into account the ongoing interactions with the affected family member. The model and its utility to identify adaptive and maladaptive responses to NoDIL is elaborated upon with clinical material obtained from caregivers of people diagnosed with major neuro-cognitive disorder and pediatric traumatic brain injury. The article concludes with implications for theory, research and clinical intervention.
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Affiliation(s)
- Einat Yehene
- School of Behavioral Sciences, The Academic College of Tel Aviv-Yaffo, Tel Aviv, Israel
| | - Alexander Manevich
- The School of Psychological Sciences and the International Laboratory for the Study of Loss, Bereavement and Human Resilience, University of Haifa, Haifa, Israel
| | - Simon Shimshon Rubin
- The School of Psychological Sciences and the International Laboratory for the Study of Loss, Bereavement and Human Resilience, University of Haifa, Haifa, Israel.,Department of Psychology, Max Stern Academic College of Emek Yezreel, Jezreel Valley, Israel
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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] [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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Caregivers of people with disorders of consciousness: which burden predictors? Neurol Sci 2020; 41:2773-2779. [PMID: 32279220 DOI: 10.1007/s10072-020-04394-6] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2020] [Accepted: 04/03/2020] [Indexed: 10/24/2022]
Abstract
OBJECTIVES Caregivers of patients diagnosed with disorders of consciousness (DoCs) play a pivotal role in the care pathway of these patients. Due to the high costs of care, among other symptoms and disorders previously described in the literature, they can manifest also mood and stress-related disorders which greatly impact their life and increase their burden. It is noteworthy to identify which factors are better related to the manifestation of mood and stress-related disorders to care for the caregivers in time. However, no studies have explored which factors are related to the manifestation of these disorders within this population yet. MATERIALS AND METHODS We explored with different questionnaires whether patient-, caregiver-, and caregiving environment-related factors are associated with mood and stress-related disorders on 114 caregivers of patients with DoCs. RESULTS Our results showed that female caregivers manifested higher levels of both depression and prolonged grief disorder; furthermore, the presence of economic problems increased the levels of depression. Moreover, different levels of caregivers' depression, anxiety, anger expression, and prolonged grief disorder were closely linked to the degree of behavioural responsiveness of the patients. CONCLUSIONS Our results highlighted the need to consider also caregivers' mood and stress-related disorders when defining the care pathway of patients with DoCs; indeed, caregivers constitute the main environment of DoC patients and they need tailored interventions aimed at reducing their burden due to caregiving.
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Peterson A, Kostick KM, O'Brien KA, Blumenthal-Barby J. Seeing minds in patients with disorders of consciousness. Brain Inj 2019; 34:390-398. [PMID: 31880960 DOI: 10.1080/02699052.2019.1706000] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
Objective: To explore the ways in which health care professionals and families understand terms and concepts associated with disorders of consciousness.Methods: Open-ended, semi-structured interviews were conducted with 20 health care professionals and 18 family caregivers affiliated with a disorders of consciousness program within a nationally ranked rehabilitation facility in the United States.Results: Analysis revealed that: (1) disagreement between some health care professionals and family caregivers regarding the presence of consciousness can arise due to differing beliefs about a patient experiencing pain, and differences in the length of time family caregivers spend with patients relative to clinical staff; (2) some health care professionals and family caregivers use nonclinical terms and concepts to describe consciousness; and (3) some family caregivers might attribute complex mental capacities to patients, which extend beyond the clinical evidence.Conclusion: The beliefs of health care professionals and families regarding disorders of consciousness are complex and could be influenced by broader psychological proclivities to "see minds" in patients who have a liminal neurological status. Awareness of these dynamics may assist health care professionals when interacting with family caregivers.
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Affiliation(s)
- Andrew Peterson
- Department of Philosophy and Institute for Philosophy and Public Policy, George Mason University, Fairfax, VA, USA
| | - Kristin M Kostick
- Center for Medical Ethics and Health Policy, Baylor College of Medicine, Houston, TX, USA
| | - Katherine A O'Brien
- Disorders of Consciousness Rehabilitation Program, TIRR Memorial Herman, Houston, TX, USA.,Department of Physical Medicine and Rehabilitation, Baylor College of Medicine, Houston, TX, USA
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Yehene E, Zaksh Y, Davidian M, Bar-Nadav O, Elyashiv M. Locked-in your heart-shaped box: Familial-role and attachment orientation as predictors of grief in prolonged disorders of consciousness vs. death. DEATH STUDIES 2019; 44:510-520. [PMID: 30938582 DOI: 10.1080/07481187.2019.1586795] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/09/2023]
Abstract
Death or prolonged disorders of consciousness (DOC) of a loved one are both considered relational-losses that severely disrupt attachment-bonds. Grief in both conditions was compared by exploring the impact of familial-role and attachment-orientation. In DOC, caregivers' grief was found significantly intensified relative to Death. Familial-role impacted grief in both conditions alike, with partners' heightened grief in DOC reflecting the complexity of their stagnant bonds. In Death, avoidance-attachment mitigated grief, while in DOC anxiety-attachment accentuated grief, we suggest that while physical-separation in death facilitates the modification of continuing attachment-schema, in DOC, modification may be required while the patient is still alive.
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Affiliation(s)
- Einat Yehene
- School of Behavioral Sciences, The Academic College of Tel Aviv - Yafo, Tel-Aviv-Yafo, Israel
| | - Yael Zaksh
- School of Behavioral Sciences, The Academic College of Tel Aviv - Yafo, Tel-Aviv-Yafo, Israel
| | - Meital Davidian
- School of Behavioral Sciences, The Academic College of Tel Aviv - Yafo, Tel-Aviv-Yafo, Israel
| | - Ofri Bar-Nadav
- International Center for the Study of Loss, Bereavement and Human Resilience, Department of Psychology, University of Haifa, Haifa, Israel
| | - Maya Elyashiv
- Respiratory Rehabilitation Division, Reut Medical-Rehabilitation Center, Tel-Aviv-Yafo, Israel
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