Understanding a liminal condition: Comparing emerging representations of the “vegetative state”

Making sense of absent-yet-present others: Representing the liminal vegetative state beyond life and death

Clinically alive yet enduringly unaware, individuals in a vegetative state are caught in their transition between life and death. In turn, their carers struggle to signify the ontological and interactional dilemmas emerging from their liminal relations with an absent-yet-present other and their suspension in time. Drawing on social representations and liminality theories, this study investigates how relatives and professionals deal with these dilemmas. In doing so, the study focuses on the role of relations and time in signifying an absent-yet-present other. We analysed 65 semi-structured interviews with relatives (n = 35) and professionals (n = 30) recruited from five Italian nursing homes between February 2019 and September 2021. A discourse-oriented thematic analysis shows how carers de-anchor patients from dichotomous categories and temporalities (e.g., life/death, person/body, past/future), representing them as existing in an ontological paradox: both/neither and and/nor. The analysis also shows how carers deal with the dilemmas of interacting with a voiceless patient by engaging in collaborative identity work. On the one hand, relatives draw on - and share - memories from the patient's past to construct a 'new identity' and 'present' for their loved ones. On the other, professionals add 'clinical identities' rooted in medical characteristics and promote corporeal communication with voiceless patients. The study highlights how carers can signify their (shared) present, everyday caring activities, and deal with an only apparently meaningless situation by mobilising the patients' pasts and promoting a corporeal sociality.

The liminal experience of awaiting for a cadaveric kidney donation: "I would not wish it on even my enemy!"

This study aims to explore the concept of liminality in the lives of chronic kidney disease (CKD) patients in Turkiye who are undergoing dialysis while awaiting kidney transplants. The research focuses on how patients experience this transitional state, being between life stages, and how they cope with the uncertainty of their condition while aspiring for a transplant. The research involved in-depth, semi-structured interviews and participant observations of 34 dialysis patients who had been registered on the national organ waiting list for over five years. The research was conducted between August 16, 2022, and November 11, 2022. The principal findings reveal that these patients experience profound uncertainty and hope, viewing potential transplants as a "second birthday" and symbolic rebirth. The study also highlights significant cultural and familial dynamics influencing the organ donation process, with many patients facing disappointment when relatives are unwilling or unable to donate. Additionally, patients report various physical and psychological challenges, including social isolation, strict dietary restrictions, and the emotional toll of dependence on hemodialysis. The significant conclusions indicate that the anticipation of receiving a cadaveric organ donation provides both hope and anxiety, motivating patients to adhere strictly to medical advice while coping with the emotional burden of uncertainty. The research underscores the complex interplay between cultural beliefs, medical practices, and the lived experiences of CKD patients. This paper contributes to knowledge by comprehensively understanding the cultural and emotional dimensions of the dialysis experience in Turkey. It offers valuable insights for healthcare providers and policymakers to improve patient care and support systems.

Disorders of Consciousness Rehabilitation: Ethical Dimensions and Epistemic Dilemmas

Patients with disorders of consciousness who survive to discharge following severe acute brain injury may face profoundly complex medical, ethical, and psychosocial challenges during their courses of recovery and rehabilitation. Although issues encountered in caring for such patients during acute hospitalization have received substantial attention, ethical challenges that may arise in subacute and chronic phases have been underexplored. Shedding light on these issues, this article explores the landscape of normative issues in the course of treating and facilitating access to care for persons with disorders of consciousness during rehabilitation and examines potential implications for patients, clinicians, family members, and society.

Ethics Along the Continuum of Research Involving Persons with Disorders of Consciousness

Interest in disorders of consciousness (DoC) has grown substantially over the past decade and has illuminated the importance of improving understanding of DoC biology; care needs (use of monitoring, performance of interventions, and provision of emotional support); treatment options to promote recovery; and outcome prediction. Exploration of these topics requires awareness of numerous ethics considerations related to rights and resources. The Curing Coma Campaign Ethics Working Group used its expertise in neurocritical care, neuropalliative care, neuroethics, neuroscience, philosophy, and research to formulate an informal review of ethics considerations along the continuum of research involving persons with DoC related to the following: (1) study design; (2) comparison of risks versus benefits; (3) selection of inclusion and exclusion criteria; (4) screening, recruitment, and enrollment; (5) consent; (6) data protection; (7) disclosure of results to surrogates and/or legally authorized representatives; (8) translation of research into practice; (9) identification and management of conflicts of interest; (10) equity and resource availability; and (11) inclusion of minors with DoC in research. Awareness of these ethics considerations when planning and performing research involving persons with DoC will ensure that the participant rights are respected while maximizing the impact and meaningfulness of the research, interpretation of outcomes, and communication of results.

Regulating liminality: Making sense of the vegetative state and defining the limits of end-of-life action

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.

Ethics and the 2018 Practice Guideline on Disorders of Consciousness: A Framework for Responsible Implementation

The 2018 practice guideline on disorders of consciousness marks an important turning point in the care of patients with severe brain injury. As clinicians and health systems implement the guideline in practice, several ethical challenges will arise in assessing the benefits, harms, feasibility, and cost of recommended interventions. We provide guidance for clinicians when interpreting these recommendations and call on professional societies to develop an ethical framework to complement the guideline as it is implemented in clinical practice.