Disorders of Consciousness: Ethical Issues of Diagnosis, Treatment, and Prognostication

Abstract

Consciousness defines our humanity more than any other biologic phenomena that a clinician might be called upon to examine, diagnose, or treat. When family comes to the bedside of a patient, they hope to find them talking, thinking, and feeling. The complexity of consciousness allows an expansive gradation of dysfunction such that we must consider numerous potential insults, possible interventions, and often an unknown likelihood of recovery. As value-laden questions are more often in the hands of surrogate decision makers, the neurologist is given the herculean task of not only diagnosing and treating alterations of consciousness but also predicting the likely course of the disease to empower surrogates to make a choice most consistent with the preferences of the patient. The degree of uncertainty in the diagnosis and prognosis demands that the clinician consider the ethics of the diagnosis, treatment, and prognostication of disorders of consciousness. Expectations of acute and chronic care, the extent of the formal neurological investigation, the potential of therapeutic trials, the self-fulfilling prophecy that can occur with prognostication, and the challenges of shared decision making are all subjects that we explore.

Cranioplasty for patients with disorders of consciousness

“…Since patients are unable to express their wishes, their surrogates' requests for treatment should be taken into account. Although there is currently no evidence that over-caution in CP affects prognosis, clinicians should avoid making decisions that lead to selffulfilling prophecies of poor outcomes (14). For patients (15,16), in addition to protecting brain tissue, providing cosmetic benefits, and facilitating discharge home (17).…”

Physicians' decision‐making when managing pediatric patients with prolonged disorders of consciousness: A qualitative study

“…A study finding that nearly 43% of patients diagnosed with a PDOC showed signs of awareness after repeated examination suggested that factors other than lack of standardized assessment approaches may influence diagnostic accuracy [34]. The literature has already shown that pessimistic assumptions (or a pessimism bias) regarding prognosis for PDOC patients may become self-fulfilling if premature lifesustaining treatment or resuscitation is withheld on the basis of that negative prediction [35][36][37][38][39]. Other studies suggest that adopting a nihilist perspective by some clinicians with patients with moderatesevere traumatic brain injury may result in self-fulfilling prophecies [39].…”

Clinical diagnosis guidelines and neurorestorative treatment for chronic disorders of consciousness (2021 China version)

“…This aims to reduce muscle tension and avoid limb deformities or contractures. Muscle tension control and deformity prevention are done by preventing harmful irritation, maintaining a well-supported position, taking oral antispasmodic drugs (e.g., baclofen), injecting botulinum toxin into muscles, infusing baclofen through intrathecal way, or transecting the spinal motor nerve root [13][14][15].…”