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Driessen DMF, Utens CMA, Ribbers PGM, van Erp WS, Heijenbrok-Kal MH. Short-term outcomes of early intensive neurorehabilitation for prolonged disorders of consciousness: A prospective cohort study. Ann Phys Rehabil Med 2024; 67:101838. [PMID: 38830314 DOI: 10.1016/j.rehab.2024.101838] [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: 05/24/2023] [Revised: 02/23/2024] [Accepted: 03/02/2024] [Indexed: 06/05/2024]
Abstract
BACKGROUND Advances in medical care have increased survival in people with severe brain injuries and with that the number of survivors with prolonged disorders of consciousness (PDOC) has increased. In the literature, early intensive neurorehabilitation (EIN) for people with PDOC is recommended to achieve the best possible outcomes. OBJECTIVES To evaluate the frequency and extent of recovery of consciousness, mortality, complications, pain and discomfort, and medication during a nationwide EIN programme in people with PDOC after acquired brain injury. We hypothesized that level of consciousness would improve in half of people with PDOC. METHODS Prospective cohort study. People with PDOC aged 16 years and older admitted to the EIN department centralized in a single rehabilitation centre in the Netherlands (Libra Rehabilitation & Audiology) were included. The EIN delivers a subacute medical level of care and rehabilitation for a maximum duration of 14 weeks. The outcome measures were level of consciousness (CRS-R), mortality, number of complications, medication and pain/discomfort (NCS-R). RESULTS Of the 104 people included, 68 % emerged to a minimal conscious state with command-following or higher during EIN and 44 % regained consciousness. Mortality during EIN was 6 %, and 50 % of deaths followed a non-treatment decision or withdrawal of life-sustaining treatment. Almost all participants had at least 1 medical complication, leading to hospital readmission for 30 %. 73 % showed no pain or discomfort. During EIN, cardiovascular medication and analgesics were reduced by 15 %. CONCLUSIONS During the EIN programme, a large percentage of people with PDOC regained at least a minimal conscious state or even consciousness. These outcomes and the frequent medical complications in these people suggest that intensive specialized care should be offered to all people with PDOC. The outcomes of this study might help health professionals to better inform the families of people with PDOC about the short-term prognosis of PDOC. PROTOCOL REGISTRATION NUMBER The Dutch Trial Register, NL 8138.
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Affiliation(s)
- Danielle M F Driessen
- Department of Rehabilitation Medicine, Erasmus MC, University Medical Centre Rotterdam, PO Box 2040, 3000 CA, Rotterdam, the Netherlands; Libra Rehabilitation & Audiology, PO Box 1355, 5022 KE, Tilburg, the Netherlands.
| | - Cecile M A Utens
- Department of Rehabilitation Medicine, Erasmus MC, University Medical Centre Rotterdam, PO Box 2040, 3000 CA, Rotterdam, the Netherlands; Libra Rehabilitation & Audiology, PO Box 1355, 5022 KE, Tilburg, the Netherlands
| | - Prof Gerard M Ribbers
- Department of Rehabilitation Medicine, Erasmus MC, University Medical Centre Rotterdam, PO Box 2040, 3000 CA, Rotterdam, the Netherlands; Rijndam Rehabilitation, PO Box 23181, 3001 KD, Rotterdam, the Netherlands
| | - Willemijn S van Erp
- Libra Rehabilitation & Audiology, PO Box 1355, 5022 KE, Tilburg, the Netherlands; Radboud University Medical Centre, Radboud Institute for Health Sciences, Department of Primary and Community Care, Nijmegen, the Netherlands; Accolade Zorg, the Netherlands
| | - Majanka H Heijenbrok-Kal
- Department of Rehabilitation Medicine, Erasmus MC, University Medical Centre Rotterdam, PO Box 2040, 3000 CA, Rotterdam, the Netherlands; Rijndam Rehabilitation, PO Box 23181, 3001 KD, Rotterdam, the Netherlands
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Overbeek BUH, van Erp WS, Eilander HJ, Koopmans RTCM, Lavrijsen JCM. Prevalence of the Minimally Conscious State Among Institutionalized Patients in the Netherlands: A Nationwide Study. Neurology 2023; 101:e2005-e2013. [PMID: 37857492 PMCID: PMC10662977 DOI: 10.1212/wnl.0000000000207820] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2023] [Accepted: 08/03/2023] [Indexed: 10/21/2023] Open
Abstract
BACKGROUND AND OBJECTIVES The minimally conscious state (MCS) is a prolonged disorder of consciousness (pDoC) and one of the most severe outcomes of acquired brain injury. Prevalence data are scarce. The aim of this study was to establish the nationwide point prevalence of institutionalized patients in MCS in the Netherlands. METHODS This was a descriptive cross-sectional study in which all 86 Dutch hospitals, all 5 specialized pDoC rehabilitation facilities, and all 274 nursing homes were asked whether they were treating patients with a pDoC on the point prevalence date of September 15, 2021. Each patient's legal representative provided informed consent for their inclusion. Patient level of consciousness was verified using the Coma Recovery Scale-Revised (CRS-R) in a single assessment session performed in the facility of residence by an experienced physician. Data on patient demographics, etiology, level of consciousness, facility of residence, and clinical status were collected from a questionnaire by the treating physician. The prevalence of institutionalized patients in MCS of per 100,000 members of the Dutch population was calculated, based on actual census data. RESULTS Seventy patients were reported to have a pDoC, of whom 6 were excluded. The level of consciousness was verified for 49 patients while for 15, it could not be verified. Of the patients verified, 38 had a pDoC, of whom 32 were in MCS (mean age 44.8 years, 68.8% male). The prevalence of institutionalized patients in MCS is 0.2-0.3 per 100,000 Dutch inhabitants. Traumatic brain injury was present in 21 of 32 patients (65.6%). Specialized pDoC rehabilitation was received by 17 of 32 patients (53%), with the rest admitted to nursing homes. The most frequent signs of consciousness on the CRS-R were visual pursuit, reproducible movement to command, and automatic motor response. DISCUSSION This nationwide study revealed a low prevalence of institutionalized patients in MCS in the Netherlands. These findings are now being used to organize pDoC care in this country.
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Affiliation(s)
- Berno U H Overbeek
- From the Department of Primary and Community Care (B.U.H.O., W.S.v.E., H.J.E., R.T.C.M.K., J.C.M.L.), Radboud University Medical Center, Research Institute of Medical Innovation; Kalorama (B.U.H.O.), Beek-Ubbergen; Azora (B.U.H.O.), Terborg; Accolade Zorg (W.S.v.E.), Bosch en Duin; Libra Rehabilitation & Audiology (W.S.v.E.), Tilburg; and Joachim and Anna, Center for Specialized Geriatric Care (R.T.C.M.K.), Nijmegen, the Netherlands.
| | - Willemijn S van Erp
- From the Department of Primary and Community Care (B.U.H.O., W.S.v.E., H.J.E., R.T.C.M.K., J.C.M.L.), Radboud University Medical Center, Research Institute of Medical Innovation; Kalorama (B.U.H.O.), Beek-Ubbergen; Azora (B.U.H.O.), Terborg; Accolade Zorg (W.S.v.E.), Bosch en Duin; Libra Rehabilitation & Audiology (W.S.v.E.), Tilburg; and Joachim and Anna, Center for Specialized Geriatric Care (R.T.C.M.K.), Nijmegen, the Netherlands
| | - Henk J Eilander
- From the Department of Primary and Community Care (B.U.H.O., W.S.v.E., H.J.E., R.T.C.M.K., J.C.M.L.), Radboud University Medical Center, Research Institute of Medical Innovation; Kalorama (B.U.H.O.), Beek-Ubbergen; Azora (B.U.H.O.), Terborg; Accolade Zorg (W.S.v.E.), Bosch en Duin; Libra Rehabilitation & Audiology (W.S.v.E.), Tilburg; and Joachim and Anna, Center for Specialized Geriatric Care (R.T.C.M.K.), Nijmegen, the Netherlands
| | - Raymond T C M Koopmans
- From the Department of Primary and Community Care (B.U.H.O., W.S.v.E., H.J.E., R.T.C.M.K., J.C.M.L.), Radboud University Medical Center, Research Institute of Medical Innovation; Kalorama (B.U.H.O.), Beek-Ubbergen; Azora (B.U.H.O.), Terborg; Accolade Zorg (W.S.v.E.), Bosch en Duin; Libra Rehabilitation & Audiology (W.S.v.E.), Tilburg; and Joachim and Anna, Center for Specialized Geriatric Care (R.T.C.M.K.), Nijmegen, the Netherlands
| | - Jan C M Lavrijsen
- From the Department of Primary and Community Care (B.U.H.O., W.S.v.E., H.J.E., R.T.C.M.K., J.C.M.L.), Radboud University Medical Center, Research Institute of Medical Innovation; Kalorama (B.U.H.O.), Beek-Ubbergen; Azora (B.U.H.O.), Terborg; Accolade Zorg (W.S.v.E.), Bosch en Duin; Libra Rehabilitation & Audiology (W.S.v.E.), Tilburg; and Joachim and Anna, Center for Specialized Geriatric Care (R.T.C.M.K.), Nijmegen, the Netherlands
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Sanz LR, Laureys S, Gosseries O. Towards modern post-coma care based on neuroscientific evidence. Int J Clin Health Psychol 2023; 23:100370. [PMID: 36817874 PMCID: PMC9932483 DOI: 10.1016/j.ijchp.2023.100370] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2022] [Accepted: 01/12/2023] [Indexed: 02/05/2023] Open
Abstract
Background Understanding the mechanisms underlying human consciousness is pivotal to improve the prognostication and treatment of severely brain-injured patients. Consciousness remains an elusive concept and the identification of its neural correlates is an active subject of research, however recent neuroscientific advances have allowed scientists to better characterize disorders of consciousness. These breakthroughs question the historical nomenclature and our current management of post-comatose patients. Method This review examines the contribution of consciousness neurosciences to the current clinical management of severe brain injury. It investigates the major impact of consciousness disorders on healthcare systems, the scientific frameworks employed to identify their neural correlates and how evidence-based data from neuroimaging research have reshaped the landscape of post-coma care in recent years. Results Our increased ability to detect behavioral and neurophysiological signatures of consciousness has led to significant changes in taxonomy and clinical practice. We advocate for a multimodal framework for the management of severely brain-injured patients based on precision medicine and evidence-based decisions, integrating epidemiology, health economics and neuroethics. Conclusions Major progress in brain imaging and clinical assessment have opened the door to a new era of post-coma care based on standardized neuroscientific evidence. We highlight its implications in clinical applications and call for improved collaborations between researchers and clinicians to better translate findings to the bedside.
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Affiliation(s)
- Leandro R.D. Sanz
- Coma Science Group, GIGA Consciousness, University of Liège, Liège, Belgium
- Centre du Cerveau, University Hospital of Liège, Liège, Belgium
| | - Steven Laureys
- Coma Science Group, GIGA Consciousness, University of Liège, Liège, Belgium
- Centre du Cerveau, University Hospital of Liège, Liège, Belgium
- Joint International Research Unit on Consciousness, CERVO Brain Research Centre, CIUSS, Laval University, Québec, Canada
| | - Olivia Gosseries
- Coma Science Group, GIGA Consciousness, University of Liège, Liège, Belgium
- Centre du Cerveau, University Hospital of Liège, Liège, Belgium
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Ordoñez Torres K, Walter Araya A. ¿Es proporcionado suspender la nutrición e hidratación artificial en pacientes con pronóstico incierto? REVISTA LATINOAMERICANA DE BIOÉTICA 2022. [DOI: 10.18359/rlbi.5711] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/08/2023] Open
Abstract
Para llevar a cabo esta investigación, se revisó la literatura sobre el caso de Terri Schiavo, paciente que se encontraba en estado vegetativo persistente y quien falleció luego de dos semanas, después de que se le suspendiera su alimentación e hidratación; se validó su diagnóstico y se indagó si fue una paciente terminal, así como también se verificó la evidencia disponible, en relación con la hidratación y nutrición artificial en este tipo de pacientes, para determinar la concordancia de estas medidas. Esta información fue analizada desde la perspectiva nutricional y bioética; en la búsqueda bibliográfica se consultaron las bases de datos Scopus, Scielo y PubMed, con los criterios de búsqueda nutrición e hidratación artificial en pacientes terminales y de pronóstico incierto. Estos hallazgos fueron analizados con el modelo de proporcionalidad terapéutica de Calipari. Por lo anterior, se determinó que la nutrición e hidratación artificial configuraban tratamientos de carácter obligatorio u optativo para Terri. Sin embargo, pese a que no existe información concluyente sobre la nutrición e hidratación artificial en pacientes terminales, ni de pronóstico incierto, se recomienda la evaluación caso a caso de parte del equipo médico, para determinar la proporcionalidad de estos procedimientos en conjunto con el paciente y su familia. Cabe resaltar que son necesarios más estudios para proporcionar mejor evidencia que permita contar con elementos objetivos para una mejor toma de decisiones.
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The validity, reliability and feasibility of four instruments for assessing the consciousness of stroke patients in a neurological intensive care unit compared. BMC Med Res Methodol 2022; 22:102. [PMID: 35395722 PMCID: PMC8991649 DOI: 10.1186/s12874-022-01580-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2021] [Accepted: 03/21/2022] [Indexed: 01/09/2023] Open
Abstract
Background Early rehabilitation is the foundation for recovery for those admitted to an intensive care unit. Appropriate assessment of consciousness is needed before any rehabilitative intervention begins. Methods This prospective study compared the validity, reliability and applicability of the sedation-agitation scale, the Richmond Agitation-Sedation Scale, the motor activity assessment scale and the Glasgow Coma Scale in a working neurological intensive care unit. Eighty-three stroke patients were assessed with the four scales by the same 3 raters acting independently: a senior physician, a senior therapist and a trainee. That generated 996 assessment records for comparison. Results Good agreement (r=0.98–0.99) was found among the sedation-agitation scale, the Richmond Agitation-Sedation Scale, the motor activity assessment scale scores, but the Glasgow Coma Scale ratings correlated less well (r=0.72–0.76) with the others. Consistent results were also found among the three raters. After stratification of the ratings by age, gender, level of consciousness and Acute Physiology and Chronic Health Evaluation score, the scales reported significant differences among the levels of consciousness and among those with different Acute Physiology and Chronic Health Evaluation results, but not with different age or gender strata. Conclusions The four instruments tested are all reliable enough and feasible for use as a tool for consciousness screening in a neurological intensive care unit.
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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 DOI: 10.1093/brain/awab290] [Citation(s) in RCA: 40] [Impact Index Per Article: 13.3] [Reference Citation Analysis] [Abstract] [Key Words] [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 unusually prolonged disorders of consciousness associated with coronavirus disease 2019 (COVID-19) 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 up until 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 persons 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.,Spaulding Rehabilitation Hospital, Charlestown, MA 02129, USA
| | | | - Joseph J Fins
- Division of Medical Ethics, Weill Cornell Medical College, New York, NY 10021, 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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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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