Prognostication, Ethical Issues, and Palliative Care in Disorders of Consciousness

Challenging Yet Rewarding: Staff Experiences in Prolonged Disorders of Consciousness Rehabilitation

OBJECTIVES

This study explored the experiences and needs of healthcare professionals providing specialized neurorehabilitation for patients with prolonged disorders of consciousness (PDOC) in post-acute and long-term care settings.

DESIGN

A qualitative study within the nationwide PDOC chain-of-care, including early intensive neurorehabilitation (EIN) in one rehabilitation center and prolonged intensive neurorehabilitation (PIN) in 3 specialized nursing homes up to 2 years post-injury.

SETTING AND PARTICIPANTS

Fifty-two healthcare professionals (nurses, physicians, and rehabilitation therapists) aged ≥ 18 working at either EIN or PIN with at least 1 year working experience in PDOC care were included.

METHODS

Five discipline-specific focus group discussions, 2 in-depth interviews, and 9 written testimonies were conducted between November 2021 and May 2022. Data were thematically analyzed.

RESULTS

Five themes describing rewarding aspects- complexity of work, providing meaningful care to patients, supporting families, multidisciplinary collaborations within teams and care network, works' personal impact and professional enrichment- and 4 themes describing challenging aspects- confrontation with patients' condition and families' grief, moral distress, complex interaction with families, personal and professional impact- were identified. For sustainability, healthcare professionals need improved working conditions, specialized training (especially communication skills and resilience trainings), and psychological support to deal with both families' expectations and moral distress. They also urged for better family support systems and continued improvement in care procedures.

CONCLUSION AND IMPLICATIONS

This study emphasizes the challenging yet rewarding nature of specialized neurorehabilitation for patients with PDOC and its impact on healthcare professionals while highlighting their unmet needs. These insights can be implemented to improve existing care programs and establish criteria for institutions delivering this care. Acknowledging burdensome aspects of this work, investment in the well-being of professionals by their employers and policy reforms focused on improved working conditions, specialized training, and psychological support is crucial for sustainable and resilient PDOC care.

Medical complications and advance medical decision-making in the minimally conscious state

OBJECTIVES

Medical complications occur frequently in MCS and influence advance medical decision-making. This study aimed to report on medical complications and advance medical decision-making in a nationwide group of MCS patients.

METHODS

In this descriptive cross-sectional study, clinical and advance medical decision-making characteristics were collected in a survey, completed by the treating physician.

RESULTS

The MCS population consisted of 32 patients: 65.6% traumatic etiology, 68.8% male. Patients had a median of five complications: hypertonia/spasticity (81.3%) and pneumonia (50.0%) occurred most frequently. Most patients had curative goals: three patients had a fully curative treatment scenarios, 29 a curative scenario with ≥ 1 treatment restrictions, two a palliative and two a symptomatic scenario. Conversations about advance medical decision-making were complicated by disputes with next of kin, inability to evaluate medical treatment because of medical instability, next of kin not being ready to discuss medical treatment, or a treatment scenario explicitly based on requests of next of kin.

CONCLUSION

Medical complications are common in MCS patients and advance medical decision making was complicated. This legitimates realization of specialized care across acute, post-acute and long-term care. Further longitudinal research into advance medical decision-making is recommended.

Emerging ethical issues in patients with disorders of consciousness: A clinical guide

Clinicians who manage patients with disorders of consciousness (DoC) commonly encounter challenging ethical issues. Consciousness disorders include the vegetative state, the minimally conscious state, and covert consciousness resulting from cognitive-motor dissociation. The practice landscape of ethical issues encompasses making the correct diagnosis; making and communicating an accurate prognosis despite irreducible uncertainty; conducting effective shared decision-making with a lawful surrogate decision-maker to deliver goal-concordant care; providing optimal medical, rehabilitative, and palliative care across the spectrum of care sites: acute inpatient, neurorehabilitative, chronic, and palliative; respecting the human rights of and advocating for DoC patient, an historically under-served population and, when appropriate, properly participating in decisions to withhold or withdraw life-sustaining therapy. Research and translational issues in DoC patients include the challenges posed by emerging diagnostics and therapeutics and their prudential integration into clinical practice in the service of patients and their families. Our conceptual analysis of these ethical issues and our practical advice to address them comprise the subject material of this chapter.

Neurologic prognostication in coma and disorders of consciousness

Coma and disorders of consciousness (DoC) are clinical syndromes primarily resulting from severe acute brain injury, with uncertain recovery trajectories that often necessitate prolonged supportive care. This imposes significant socioeconomic burdens on patients, caregivers, and society. Predicting recovery in comatose patients is a critical aspect of neurocritical care, and while current prognostication heavily relies on clinical assessments, such as pupillary responses and motor movements, which are far from precise, contemporary prognostication has integrated more advanced technologies like neuroimaging and electroencephalogram (EEG). Nonetheless, neurologic prognostication remains fraught with uncertainty and significant inaccuracies and is impacted by several forms of prognostication biases, including self-fulfilling prophecy bias, affective forecasting, and clinician treatment biases, among others. However, neurologic prognostication in patients with disorders of consciousness impacts life-altering decisions including continuation of treatment interventions vs withdrawal of life-sustaining therapies (WLST), which have a direct influence on survival and recovery after severe acute brain injury. In recent years, advancements in neuro-monitoring technologies, artificial intelligence (AI), and machine learning (ML) have transformed the field of prognostication. These technologies have the potential to process vast amounts of clinical data and identify reliable prognostic markers, enhancing prediction accuracy in conditions such as cardiac arrest, intracerebral hemorrhage, and traumatic brain injury (TBI). For example, AI/ML modeling has led to the identification of new states of consciousness such as covert consciousness and cognitive motor dissociation, which may have important prognostic significance after severe brain injury. This chapter reviews the evolving landscape of neurologic prognostication in coma and DoC, highlights current pitfalls and biases, and summarizes the integration of clinical examination, neuroimaging, biomarkers, and neurophysiologic tools for prognostication in specific disease states. We will further discuss the future of neurologic prognostication, focusing on the integration of AI and ML techniques to deliver more individualized and accurate prognostication, ultimately improving patient outcomes and decision-making process in neurocritical care.

Acupuncture-assisted therapy for prolonged disorders of consciousness: study protocol for a randomized, conventional-controlled, assessor-and-statistician-blinded trial

Background

Acupuncture is a promising non-pharmaceutical complementary therapy in treating prolonged Disorders of consciousness (pDOC), but solid evidence to support its effectiveness and safety is still lacking. Thus, the purpose of this study is to investigate the efficacy and safety of acupuncture-assisted therapy for pDOC patients.

Methods

A single-center, prospective, randomized, conventional-controlled, assessor-and-statistician-blinded trial has been designed and is being conducted at West China Hospital of Sichuan University. A total of 110 participants will be randomly assigned to the experimental group and the control group in a 1:1 allocation ratio and evaluated using Coma Recovery Scale-Revised (CRS-R) at 8 a.m., 12 p.m., and 4 p.m. on 2 consecutive days before enrollment to determine the consciousness level. The experimental group will receive acupuncture combined with conventional treatment, while the control group will receive only conventional treatment during the trial observation period. The treatment duration of both groups will be 20 days. Among them, the frequency of acupuncture-assisted therapy is once a day, with 10 consecutive sessions followed by a day's rest for a total of 24 days. Data will be collected separately during baseline and after the final treatment. For data analysis, both Full Analysis Set (FAS) and Per Protocol Set (PPS) principles will be performed together by applying SPSS 27.0 software. The primary outcome measures are the changes of CRS-R before and after treatment, while the secondary outcome measures are the changes of Full Outline of Unresponsiveness Scale (FOUR), the changes of Nociception Coma Scale-Revised (NCS-R), the changes of Disability Rating Scale (DRS), the changes of Mismatch Negativity (MMN) and P300 before and after treatment, respectively.

Discussion

This trial aims to rationally assess the consciousness level from multiple 2 perspectives through subjective evaluation and objective detection by selecting several standardized clinical scales combined with Event-Related Potential (ERP) detection technology. In this way, we will be able to reduce the subjectivity of consciousness assessment and objectively evaluate the clinical efficacy of acupuncture-assisted therapy for pDOC. The study, if proven to be effective and safe enough, will provide a favorable evidence to guide medical decision-making choices and future researches.

Clinical trial registration

https://www.chictr.org.cn/, identifier ChiCTR2300076180.

Artificial nutrition in cerebrovascular disease, necessity or futility: Case report

Introduction

Stroke is one of the leading causes of mortality and disability in the world, with clinical manifestations and severe complications that they negatively affect the patient's recovery, contributing to an uncertain prognosis and difficult decisions with bioethical dilemmas such as artificial nutrition in the context of severe stroke.

Presentation of the case

A 49-year-old patient with a Cerebrovascular Accident in a chronic vegetative state, tracheostomy, and gastrostomy user, admitted for infectious complications, whom, under therapeutic proportionality, the decision is made, shared by medical staff and family, to withdraw artificial nutrition.

Conclusions

Difficult decision-making involves multiple challenges for both the health personnel and the patient and his or her environment. It must be guided by bioethical principles and proportionality in favor of the quality of life and the patient's benefit.

Natural course and predictors of consciousness recovery in children with prolonged disorder of consciousness

Prolonged disorder of consciousness (DoC) is a rising challenge. Pediatric data on diagnosis and prognosis of prolonged DoC were too limited and heterogeneous, making it difficult to define the natural course and evaluate the prognosis. The present study explored the emergence from the Minimally Conscious State (eMCS) incidence at different months postinjury drawing the natural course, and detected the predictors of the incidence in children with prolonged DoC. A hospital-based prospective cohort study was conducted. Kaplan-Meier curves, as well as univariate and multivariate COX regression analysis, were performed. The study enrolled 383 pediatric DoC individuals, including 220 males (57.4%), with an average age of 3.9 (1.9-7.3) years. The median duration between onset and rehabilitation is 30.0 (21.0-46.0) days. At enrollment, the ratio of vegetative state/unresponsive wakefulness syndrome (VS/WUS) to MCS is 78.9%-21.1%. Traumatic brain injury and infection are the major etiologies (36.8% and 37.1%, respectively), followed by hypoxia cerebral injury (12.3%). For children with prolonged DoC, the cumulative incidence of eMCS at months 3, 6, 12, and 24 was 0.510, 0.652, 0.731, 0.784 VS 0.290, 0.418, 0.539, 0.603 in the traumatic VS non-traumatic subgroup, respectively. For children in a persistent vegetative state (PVS), the cumulative incidence of emergence at months in 3, 6, 12, 24, 36 and 48 was testified as 0.439, 0.591, 0.683, 0.724, 0.743 and 0.743 in the traumatic subgroup, and 0.204, 0.349, 0.469, 0.534, 0.589 and 0.620 in the non-traumatic subgroup. Participants who exhibit any of the following four demographical and/or clinical characteristics-namely, older than 4 years at onset, accepted rehabilitation within 28 days of onset, remained MCS at enrollment, or with etiology of traumatic brain injuries-had a significantly positive outcome of consciousness recovery (eMCS). Moreover, both prolongation of the central somatosensory conductive time (CCT) (level 2) and absence of N20 (level 3) independently predict a negative outcome. In children with prolonged DoC, we found that 12 months postinjury was critical to eMCS, and a preferred timepoint to define chronic vegetative state (VS). The characteristics including age, etiology, time before rehabilitation, consciousness state, and SEP results were useful predictors of conscious recovery.Trial registration Registered 06/11/2018, the registration number is chiCTR1800019330 (chictr.org.cn). Registered prospectively.