Assessment of Covert Consciousness in the Intensive Care Unit: Clinical and Ethical Considerations

Covert Consciousness: Searching for Volitional Brain Activity in the Unresponsive

Consciousness may evade detection by bedside behavioral examination. New research suggests that an electrophysiologic screening tool can identify people with severe brain injuries who are likely to be covertly conscious.

Covert Consciousness in the Intensive Care Unit

Claassen et al. performed task-based electroencephalography (EEG) in patients with disorders of consciousness in the intensive care unit (ICU) and found that covert consciousness detected by EEG is associated with better long-term outcomes. The diagnostic and prognostic uncertainty raised by these findings lead to pressing ethical questions concerning clinical management.

Disorders of Consciousness, Past, Present, and Future

This paper, presented as the 2019 Cambridge Quarterly Neuroethics Network Charcot Lecture, traces the nosology of disorders of consciousness in light of 2018 practice guidelines promulgated by the American Academy of Neurology, the American College of Rehabilitation Medicine and the National Institute on Disability, Independent Living and Rehabilitation Research. By exploring the ancient origins of Jennett and Plum’s persistent vegetative state and subsequent refinements in the classification of disorders of consciousness—epitomized by the minimally conscious state, cognitive motor dissociation, and the recently described chronic vegetative state—the author argues that there is a counter-narrative to the one linking these conditions to the right to die. Instead, there is a more nuanced schema distinguishing futility from utility, informed by technical advances now able to identify covert consciousness contemplated by Jennett and Plum. Their prescience foreshadows recent developments in the disorders of consciousness literature yielding a layered legacy with implications for society’s normative and legal obligations to these patients.