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Farisco M, Formisano R, Gosseries O, Kato Y, Koboyashi S, Laureys S, Lejeune N, Martial C, Matar A, Morrisey AM, Schnakers C, Yakufujiang M, Yamaki T, Veeramuthu V, Zandalasini M, Zasler N, Magliacano A, Estraneo A. International survey on the implementation of the European and American guidelines on disorders of consciousness. J Neurol 2024; 271:395-407. [PMID: 37740739 PMCID: PMC10770208 DOI: 10.1007/s00415-023-11956-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2023] [Revised: 08/17/2023] [Accepted: 08/18/2023] [Indexed: 09/25/2023]
Abstract
Diagnostic, prognostic, and therapeutic procedures for patients with prolonged disorders of consciousness (pDoCs) vary significantly across countries and clinical settings, likely due to organizational factors (e.g., research vs. non-academic hospitals), expertise and availability of resources (e.g., financial and human). Two international guidelines, one from the European Academy of Neurology (EAN) and one from the American Academy of Neurology (AAN) in collaboration with the American Congress of Rehabilitation Medicine (ACRM) and the National Institute on Disability, Independent Living, and Rehabilitation Research (NIDILRR), were developed to facilitate consistent practice among professionals working with this challenging patient population. While the recommendations of both guidelines agree in principle, it remains an open issue how to implement them into clinical practice in the care pathway for patients with pDoCs. We conducted an online survey to explore health professional clinical practices related to the management of patients with pDoCs, and compare said practices with selected recommendations from both the guidelines. The survey revealed that while some recommendations are being followed, others are not and/or may require more honing/specificity to enhance their clinical utility. Particular attention should be given to the implementation of a multimodal assessment of residual consciousness, to the detection and treatment of pain, and to the impact of restrictions imposed by COVID-19 pandemics on the involvement of patients' families/representatives.
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Affiliation(s)
- Michele Farisco
- Centre for Research Ethics and Bioethics, Uppsala University, Uppsala, Sweden.
- Biogem, Biology and Molecular Genetics Research Institute, Ariano Irpino, AV, Italy.
| | | | - Olivia Gosseries
- Coma Science Group, GIGA-Consciousness, University of Liège, Liège, Belgium
- Centre du Cerveau, University Hospital of Liège, Liège, Belgium
| | - Yoko Kato
- Department of Neurosurgery, Fujita Health University Bantane Hospital, Nagoya, Aichi, Japan
| | - Shigeki Koboyashi
- Division of Neurosurgery, Rehabilitation Center for Traumatic Apallics Chiba, National Agency for Automotive Safety and Victims' Aid, 3-30-1 Isobe, Mihamaku, Chibashi, Chiba, 261-0012, Japan
| | - Steven Laureys
- Coma Science Group, GIGA-Consciousness, University of Liège, Liège, Belgium
- Centre du Cerveau, University Hospital of Liège, Liège, Belgium
- CERVO Brain Research Center, University of Laval, Québec, QC, Canada
| | - Nicolas Lejeune
- Coma Science Group, GIGA-Consciousness, University of Liège, Liège, Belgium
- CHN William Lennox, Ottignies-Louvain-La Neuve, Belgium
- Institute of NeuroScienceUCLouvain, Ottignies-Louvain-La Neuve, Belgium
| | - Charlotte Martial
- Coma Science Group, GIGA-Consciousness, University of Liège, Liège, Belgium
- Centre du Cerveau, University Hospital of Liège, Liège, Belgium
| | - Amal Matar
- Centre for Research Ethics and Bioethics, Uppsala University, Uppsala, Sweden
| | - Ann-Marie Morrisey
- School of Allied Health, Faculty of Education and Health Sciences, Ageing Research Centre, Health Research Institute, University of Limerick, Limerick, Ireland
| | - Caroline Schnakers
- Research Institute, Casa Colina Hospital and Centers for Healthcare, Pomona, CA, USA
| | - Maidinamu Yakufujiang
- Division of Neurosurgery, Rehabilitation Center for Traumatic Apallics Chiba, National Agency for Automotive Safety and Victims' Aid, 3-30-1 Isobe, Mihamaku, Chibashi, Chiba, 261-0012, Japan
| | - Tomohiro Yamaki
- Division of Neurosurgery, Rehabilitation Center for Traumatic Apallics Chiba, National Agency for Automotive Safety and Victims' Aid, 3-30-1 Isobe, Mihamaku, Chibashi, Chiba, 261-0012, Japan
| | | | - Matteo Zandalasini
- Unità Spinale, Neuroriabilitazione E Medicina Riabilitativa Intensiva, Dipartimento Di Medicina Riabilitativa, Azienda USL Di Piacenza, Piacenza, Italy
| | - Nathan Zasler
- Concussion Care Centre of Virginia, LTD, Henrico, VA, 23233, USA
- Department of Physical Medicine and Rehabilitation, Virginia Commonwealth University, Richmond, VA, 23298, USA
| | - Alfonso Magliacano
- IRCCS Fondazione Don Carlo Gnocchi ONLUS, Florence and Sant'Angelo dei Lombardi, AV, Italy
| | - Anna Estraneo
- IRCCS Fondazione Don Carlo Gnocchi ONLUS, Florence and Sant'Angelo dei Lombardi, AV, Italy
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Lewis A, Young MJ, Rohaut B, Jox RJ, Claassen J, Creutzfeldt CJ, Illes J, Kirschen M, Trevick S, Fins JJ. Ethics Along the Continuum of Research Involving Persons with Disorders of Consciousness. Neurocrit Care 2023; 39:565-577. [PMID: 36977963 PMCID: PMC11023737 DOI: 10.1007/s12028-023-01708-2] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2022] [Accepted: 02/23/2023] [Indexed: 03/30/2023]
Abstract
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.
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Affiliation(s)
- Ariane Lewis
- NYU Langone Medical Center, 530 First Avenue, Skirball-7R, New York, NY, 10016, USA.
| | - Michael J Young
- Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Benjamin Rohaut
- Inserm, CNRS, APHP - Hôpital de la Pitié Salpêtrière, Paris Brain Institute - ICM, DMU Neuroscience, Sorbonne University, Paris, France
| | - Ralf J Jox
- Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
| | - Jan Claassen
- New York Presbyterian Hospital, Columbia University, New York, NY, USA
| | - Claire J Creutzfeldt
- Harborview Medical Center, Seattle, WA, USA
- University of Washington, Seattle, WA, USA
- Cambia Palliative Care Center of Excellence, Seattle, WA, USA
| | - Judy Illes
- University of British Columbia, Vancouver, BC, Canada
| | | | | | - Joseph J Fins
- Weill Cornell Medical College, New York, NY, USA
- Yale Law School, New Haven, CT, USA
- Rockefeller University, New York, NY, USA
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Rohaut B. Disorders of Consciousness: navigating between nihilism and unrealistic hopes. Presse Med 2023; 52:104182. [PMID: 37827212 DOI: 10.1016/j.lpm.2023.104182] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/06/2023] [Accepted: 10/06/2023] [Indexed: 10/14/2023] Open
Affiliation(s)
- Benjamin Rohaut
- Sorbonne Université, Paris, France; Médecine Intensive Réanimation à orientation Neurologique, DMU Neurosciences, AP-HP, Hôpital de la Pitié-Salpêtrière, Paris, France; Institut du Cerveau, Paris Brain Institute, ICM, PICNIC-Lab, Inserm, CNRS, Paris, France.
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Fingelkurts AA, Fingelkurts AA. Patients with Disorders of Consciousness: Are They Nonconscious, Unconscious, or Subconscious? Expanding the Discussion. Brain Sci 2023; 13:brainsci13050814. [PMID: 37239286 DOI: 10.3390/brainsci13050814] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2023] [Revised: 05/14/2023] [Accepted: 05/16/2023] [Indexed: 05/28/2023] Open
Abstract
Unprecedented advancements in the diagnosis and treatment of patients with disorders of consciousness (DoC) have given rise to ethical questions about how to recognize and respect autonomy and a sense of agency of the personhood when those capacities are themselves disordered, as they typically are in patients with DoC. At the intersection of these questions rests the distinction between consciousness and unconsciousness. Indeed, evaluations of consciousness levels and capacity for recovery have a significant impact on decisions regarding whether to discontinue or prolong life-sustaining therapy for DoC patients. However, in the unconsciousness domain, there is the confusing array of terms that are regularly used interchangeably, making it quite challenging to comprehend what unconsciousness is and how it might be empirically grounded. In this opinion paper, we will provide a brief overview of the state of the field of unconsciousness and show how a rapidly evolving electroencephalogram (EEG) neuroimaging technique may offer empirical, theoretical, and practical tools to approach unconsciousness and to improve our ability to distinguish consciousness from unconsciousness and also nonconsciousness with greater precision, particularly in cases that are borderline (as is typical in patients with DoC). Furthermore, we will provide a clear description of three distant notions of (un)consciousness (unconsciousness, nonconsciousness, and subconsciousness) and discuss how they relate to the experiential selfhood which is essential for comprehending the moral significance of what makes life worth living.
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Luauté J, Beaudoin-Gobert M. Optimising recovery of consciousness after coma. From bench to bedside and vice versa. Presse Med 2023; 52:104165. [PMID: 36948412 DOI: 10.1016/j.lpm.2023.104165] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/04/2023] [Accepted: 03/13/2023] [Indexed: 03/24/2023] Open
Abstract
BACKGROUND Several methods have been proposed to foster recovery of consciousness in patients with disorders of consciousness (DoC). OBJECTIVE Critically assess pharmacological and non-pharmacological treatments for patients with chronic DoC. METHODS A narrative mini-review, and critical analysis of the scientific literature on the various proposed therapeutic approaches, with particular attention to level of evidence, risk-benefit ratio, and feasibility. RESULTS AND DISCUSSION Personalised sensory stimulation, median nerve stimulation, transcranial direct current stimulation (tDCS), amantadine and zolpidem all have favourable risk-benefit ratios and are easy to implement in clinical practice. These treatments should be proposed to every patient with chronic DoC. Comprehensive patient management should also include regular lifting, pain assessment and treatment, attempts to restore sleep and circadian rhythms, implementation of rest periods, comfort and nursing care, and a rehabilitation program with a multi-disciplinary team with expertise in this field. More invasive treatments may cause adverse effects and require further investigation to confirm preliminary, encouraging results and to better define responders' intervention parameters. Scientific studies are essential and given the severity of the disability and handicap that results from DoC, research in this area should aim to develop new therapeutic approaches.
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Affiliation(s)
- Jacques Luauté
- Université Claude Bernard Lyon 1, CNRS, INSERM, Centre de Recherche en Neurosciences de Lyon CRNL U1028 UMR5292, Trajectoires, F-69500, Bron, France; Hospices Civils de Lyon, Hôpital Henry Gabrielle, Saint-Genis Laval, 69230, France.
| | - Maude Beaudoin-Gobert
- Université Claude Bernard Lyon 1, CNRS, INSERM, Centre de Recherche en Neurosciences de Lyon CRNL U1028 UMR5292, Trajectoires, F-69500, Bron, France
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Sangare A, Marois C, Perlbarg V, Pyatigorskaya N, Valente M, Zyss J, Borden A, Lambrecq V, Le Guennec L, Sitt J, Weiss N, Rohaut B, Demeret S, Puybasset L, Demoule A, Naccache L. Description and Outcome of Severe Hypoglycemic Encephalopathy in the Intensive Care Unit. Neurocrit Care 2022; 38:365-377. [PMID: 36109449 DOI: 10.1007/s12028-022-01594-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2022] [Accepted: 08/18/2022] [Indexed: 11/28/2022]
Abstract
BACKGROUND Disorders of consciousness due to severe hypoglycemia are rare but challenging to treat. The aim of this retrospective cohort study was to describe our multimodal neurological assessment of patients with hypoglycemic encephalopathy hospitalized in the intensive care unit and their neurological outcomes. METHODS Consecutive patients with disorders of consciousness related to hypoglycemia admitted for neuroprognostication from 2010 to 2020 were included. Multimodal neurological assessment included electroencephalography, somatosensory and cognitive event-related potentials, and morphological and quantitative magnetic resonance imaging (MRI) with quantification of fractional anisotropy. Neurological outcomes at 28 days, 3 months, 6 months, 1 year, and 2 years after hypoglycemia were retrieved. RESULTS Twenty patients were included. After 2 years, 75% of patients had died, 5% remained in a permanent vegetative state, 10% were in a minimally conscious state, and 10% were conscious but with severe disabilities (Glasgow Outcome Scale-Extended scores 3 and 4). All patients showed pathologic electroencephalography findings with heterogenous patterns. Morphological brain MRI revealed abnormalities in 95% of patients, with various localizations including cortical atrophy in 65% of patients. When performed, quantitative MRI showed decreased fractional anisotropy affecting widespread white matter tracts in all patients. CONCLUSIONS The overall prognosis of patients with severe hypoglycemic encephalopathy was poor, with only a small fraction of patients who slowly improved after intensive care unit discharge. Of note, patients who did not improve during the first 6 months did not recover consciousness. This study suggests that a multimodal approach capitalizing on advanced brain imaging and bedside electrophysiology techniques could improve diagnostic and prognostic performance in severe hypoglycemic encephalopathy.
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Affiliation(s)
- Aude Sangare
- Physiological Investigayions of Clinically Normal and Impaired Cognition Lab, Institut du Cerveau et de la Moelle épinière, Sorbonne Université, Paris, France.
- Département de Neurophysiologie, Assistance Publique-Hôpitaux de Paris, Groupe Hospitalier Pitié-Salpêtrière Charles Foix, Sorbonne Université, Paris, France.
- Institut de Neurosciences Translationnelles, Paris, France.
- Brain Institute - ICM, Sorbonne Université, Inserm U1127, CNRS UMR 7225, 47 Boulevard de l'Hôpital, 75013, Paris, France.
| | - Clémence Marois
- Groupe Hospitalier Pitié-Salpêtrière Charles Foix, Département de Neurologie, Médecine Intensive et Réanimation à Orientation Neurologique, Assistance Publique-Hôpitaux de Paris, Sorbonne Université, Paris, France
- Groupe de Recherche Clinique en Reanimation et Soins Intensifs du Patient en Insuffisance Respiratoire Aigue Assistance Publique, Sorbonne Université, Paris, France
| | | | - Nadya Pyatigorskaya
- Département de Neuroradiologie, Assistance Publique-Hôpitaux de Paris, Groupe Hospitalier Pitié-Salpêtrière Charles Foix, Sorbonne Université, Paris, France
| | - Mélanie Valente
- Physiological Investigayions of Clinically Normal and Impaired Cognition Lab, Institut du Cerveau et de la Moelle épinière, Sorbonne Université, Paris, France
- Département de Neurophysiologie, Assistance Publique-Hôpitaux de Paris, Groupe Hospitalier Pitié-Salpêtrière Charles Foix, Sorbonne Université, Paris, France
- Institut de Neurosciences Translationnelles, Paris, France
| | - Julie Zyss
- Département de Neurophysiologie, Assistance Publique-Hôpitaux de Paris, Groupe Hospitalier Pitié-Salpêtrière Charles Foix, Sorbonne Université, Paris, France
- Institut de Neurosciences Translationnelles, Paris, France
| | - Alaina Borden
- Département de Neurophysiologie, Assistance Publique-Hôpitaux de Paris, Groupe Hospitalier Pitié-Salpêtrière Charles Foix, Sorbonne Université, Paris, France
- Institut de Neurosciences Translationnelles, Paris, France
| | - Virginie Lambrecq
- Département de Neurophysiologie, Assistance Publique-Hôpitaux de Paris, Groupe Hospitalier Pitié-Salpêtrière Charles Foix, Sorbonne Université, Paris, France
- Institut de Neurosciences Translationnelles, Paris, France
| | - Loic Le Guennec
- Groupe Hospitalier Pitié-Salpêtrière Charles Foix, Département de Neurologie, Médecine Intensive et Réanimation à Orientation Neurologique, Assistance Publique-Hôpitaux de Paris, Sorbonne Université, Paris, France
| | - Jacobo Sitt
- Physiological Investigayions of Clinically Normal and Impaired Cognition Lab, Institut du Cerveau et de la Moelle épinière, Sorbonne Université, Paris, France
| | - Nicolas Weiss
- Groupe Hospitalier Pitié-Salpêtrière Charles Foix, Département de Neurologie, Médecine Intensive et Réanimation à Orientation Neurologique, Assistance Publique-Hôpitaux de Paris, Sorbonne Université, Paris, France
- Groupe de Recherche Clinique en Reanimation et Soins Intensifs du Patient en Insuffisance Respiratoire Aigue Assistance Publique, Sorbonne Université, Paris, France
- Brain Liver Pitié-Salpêtrière Study Group, Centre de Recherche Saint-Antoine, Maladies Métaboliques, Biliaires et Fibro-Inflammatoire du Foie & Institute of Cardiometabolism and Nutrition, Sorbonne Université, Paris, France
| | - Benjamin Rohaut
- Physiological Investigayions of Clinically Normal and Impaired Cognition Lab, Institut du Cerveau et de la Moelle épinière, Sorbonne Université, Paris, France
- Groupe Hospitalier Pitié-Salpêtrière Charles Foix, Département de Neurologie, Médecine Intensive et Réanimation à Orientation Neurologique, Assistance Publique-Hôpitaux de Paris, Sorbonne Université, Paris, France
| | - Sophie Demeret
- Groupe Hospitalier Pitié-Salpêtrière Charles Foix, Département de Neurologie, Médecine Intensive et Réanimation à Orientation Neurologique, Assistance Publique-Hôpitaux de Paris, Sorbonne Université, Paris, France
| | - Louis Puybasset
- Laboratoire d'Imagerie Biomédicale, Centre National de la Recherche Scientifique, Institut National de la Santé et de la Recherche Médicale, Assistance Publique-Hôpitaux de Paris, Départements Médico-Universitaires Diagnostic, Radiologie, Explorations fonctionnelles, Anatomo-pathologie, Médecine nucléaire, Paris, France
- Department of Anesthesiology and Critical Care, Pitié-Salpêtrière Hospital, Paris, France
| | - Alexandre Demoule
- Neurophysiologie Respiratoire Expérimentale et Clinique, Institut National de la Santé et de la Recherche Médicale, Sorbonne Université, Paris, France
- Service Médecine Intensive-Réanimation, Groupe Hospitalier Pitié-Salpêtrière Charles Foix, Assistance Publique-Hôpitaux de Paris, Sorbonne Université, Paris, France
| | - Lionel Naccache
- Physiological Investigayions of Clinically Normal and Impaired Cognition Lab, Institut du Cerveau et de la Moelle épinière, Sorbonne Université, Paris, France
- Département de Neurophysiologie, Assistance Publique-Hôpitaux de Paris, Groupe Hospitalier Pitié-Salpêtrière Charles Foix, Sorbonne Université, Paris, France
- Institut de Neurosciences Translationnelles, Paris, France
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