Differences That Make a Difference in Disorders of Consciousness

Fins, Joseph J.; Schiff, Nicholas D.

doi:10.1080/21507740.2017.1380728

Cited by 11 publications

(12 citation statements)

References 38 publications

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“…It can respond to different questions and to the evolving brain states characteristic of patients with disorders of consciousness. 28 Again, the metaphor serves us well. With individual stones that can refract light depending on angle and intensity, the mosaic can represent different decisions even as they involve the same individuals.…”

Section: Aesthetics and Consensusmentioning

confidence: 99%

Mosaic Decisionmaking and Severe Brain Injury: Adding Another Piece to the Argument

Fins¹

2019

Camb Q Healthc Ethics

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Section: Aesthetics and Consensusmentioning

confidence: 99%

Mosaic Decisionmaking and Severe Brain Injury: Adding Another Piece to the Argument

Fins¹

2019

Camb Q Healthc Ethics

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“…55 These findings suggest that brain injuries are potentially dynamic and not static. 56 Remarkably, in the process of recovery, the brain is recapitulating a normal developmental process of sprouting and pruning in the service of brain repair. This suggests that the current time frame allocated to rehabilitation is inconsistent with the time course of biological recovery.…”

Section: Nosologic Humility and Neurosciencementioning

confidence: 99%

Disorders of Consciousness, Past, Present, and Future

Fins¹

2019

Camb Q Healthc Ethics

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Abstract: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.

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“…Would we rather overdiagnose covert consciousness (and the correlative ability to perceive pain) when it was not present or fail to detect it when it was present? 31 The consequences of such a diagnostic omission would be to mistake patients who are conscious as insensate and believe that analgesia is unnecessary or unjustified. When in doubt, is it not preferable to presume covert consciousness in order to assure the prevention of pain and suffering?…”

Section: Pain Management and Neuropalliative Carementioning

confidence: 99%

Ethical, palliative, and policy considerations in disorders of consciousness

Fins

Bernat

2018

Neurology

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This essay complements the scientific and practice scope of the American Academy of Neurology Guideline on Disorders of Consciousness by providing a discussion of the ethical, palliative, and policy aspects of the management of this group of patients. We endorse the renaming of "permanent" vegetative state to "chronic" vegetative state given the increased frequency of reports of late improvements but suggest that further refinement of this class of patients is necessary to distinguish late recoveries from patients who were misdiagnosed or in cognitive-motor dissociation. Additional nosologic clarity and prognostic refinement is necessary to preclude overestimation of low probability events. We argue that the new descriptor "unaware wakefulness syndrome" is no clearer than "vegetative state" in expressing the mismatch between apparent behavioral unawareness when patients have covert consciousness or cognitive motor dissociation. We advocate routine universal pain precautions as an important element of neuropalliative care for these patients given the risk of covert consciousness. In medical decision-making, we endorse the use of advance directives and the importance of clear and understandable communication with surrogates. We show the value of incorporating a learning health care system so as to promote therapeutic innovation. We support the Guideline's high standard for rehabilitation for these patients but note that those systems of care are neither widely available nor affordable. Finally, we applaud the Guideline authors for this outstanding exemplar of engaged scholarship in the service of a frequently neglected group of brain-injured patients.

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Differences That Make a Difference in Disorders of Consciousness

Cited by 11 publications

References 38 publications

Mosaic Decisionmaking and Severe Brain Injury: Adding Another Piece to the Argument

Mosaic Decisionmaking and Severe Brain Injury: Adding Another Piece to the Argument

Disorders of Consciousness, Past, Present, and Future

Ethical, palliative, and policy considerations in disorders of consciousness

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