Predicting the outcome of a comatose patient at the bedside

Wijdicks, Eelco F. M.

doi:10.1136/practneurol-2019-002359

Cited by 7 publications

(9 citation statements)

References 49 publications

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“…Both the medical team and the patient representatives wanted to ensure the ethical appropriateness of a difficult decision by initiating a CEC. Patients with neurological disorders in particular often show a reduction in awareness and it is difficult to assess the prognosis [19]. This may determine the number of CEC scenarios due to uncertainty.…”

Section: Discussionmentioning

confidence: 99%

Clinical Ethics Consultation in Neurology – a case series

et al. 2021

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Background The concept of clinical ethics consultation (CECs) was implemented to provide support in ethical controversies in clinical settings and are offered in at least every second hospital in Germany. Neurological disorders often require complex decision-making. The aims of this study were to determine which situations lead to CEC in neurology and to investigate the influence of the individual patient’s wishes on the recommendation. Methods Standardised CEC protocols in the years 2011 to 2017 at the University Hospitals of Goettingen and Jena were retrospectively surveyed. The contents were categorised along existing protocol templates of CEC scenarios and subsequently paraphrased and reduced to significant meanings. Results 27 CEC scenarios which were facilitated by various professional disciplines were reviewed. Stroke was the most frequent underlying condition. Nearly all patients were not able to consent. Mostly, the relatives acted as representatives or health advocates. In 67 % of cases, a sense of conflict triggered a CEC; in 33 % a sense of uncertainty was the reason for the CEC request. In 21 CEC scenarios, a recommendation was reached in consensus with all parties involved. In 59 % of cases, a decision was made to continue medical therapy. In seven cases, the patient’s wishes led to a limitation of therapy, while in just two cases this decision was made primarily relying on the patient’s best interest. In only 13 % of cases, a valid advance directive led to respective therapeutic consequences. Conclusions CEC is feasible for consensus-finding not only in conflicts, but also in situations of therapeutic uncertainty in neurology. There is a special importance of the patient’s wishes in decision-making in neurology. However, only in a few cases were advance directives precise and specific enough to have sufficient and decisive weight in therapeutic decision-making.

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Section: Discussionmentioning

confidence: 99%

Clinical Ethics Consultation in Neurology – a case series

et al. 2021

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“…This period is transient, and after some days or weeks, the patients may evolve to bd, losing all brainstem functions permanently, i.e., no brainstem reflexes. (58,74,75) Jahi was diagnosed with bd because her clinical examination demonstrated a sleep-like state of unarousability and unresponsiveness without evidence of self-awareness or awareness of the environment, no brainstem reflexes, no spontaneous respiratory drive (apnea), and that she required permanent mechanical ventilation. Nonetheless, ancillary tests, performed nine months after initial brain insult, showed conservation of intracranial structures, eeg activity, and autonomic reactivity to "Mother Talks" stimulus, demonstrating preserved function in both the brainstem and the cerebral hemispheres.…”

Section: Preservation Of Intracranial Structuresmentioning

confidence: 99%

“…All these findings speak against a diagnosis of bd. (6,13) She was not comatose because although she was clinically in a sleep-like state of unarousability and unresponsiveness without evidence of self-awareness or awareness of the environment, (46,58,74) the complete absence of brainstem reflexes dismissed this possibility. (6,13) Repetitive clinical assessment excluded the presence of confounding factors (e.g., drug intoxication, hypothermia) that would have explained the absence of brainstem reflexes in suspected bd.…”

Section: Preservation Of Intracranial Structuresmentioning

confidence: 99%

Jahi McMath, a New Disorder of Consciousness

Machado¹

2021

Rev. latinoam. bioet

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In this paper, I review the case of Jahi McMath, who was diagnosed with brain death (BD). Nonetheless, ancillary tests performed nine months after the initial brain insult showed conservation of intracranial structures, EEG activity, and autonomic reactivity to the “Mother Talks” stimulus. She was clinically in an unarousable and unresponsive state, without evidence of self-awareness or awareness of the environment. However, the total absence of brainstem reflexes and partial responsiveness rejected the possibility of a coma. Jahi did not have uws because she was not in a wakefulness state and showed partial responsiveness. She could not be classified as a LIS patient either because LIS patients are wakeful and aware, and although quadriplegic, they fully or partially preserve brainstem reflexes, vertical eye movements or blinking, and respire on their own. She was not in an MCS because she did not preserve arousal and preserved awareness only partially. The CRS-R resulted in a very low score, incompatible with MCS patients. mcs patients fully or partially preserve brainstem reflexes and usually breathe on their own. MCS has always been described as a transitional state between a coma and UWS but never reported in a patient with all clinical BD findings. This case does not contradict the concept of BD but brings again the need to use ancillary tests in BD up for discussion. I concluded that Jahi represented a new disorder of consciousness, non-previously described, which I have termed “reponsive unawakefulness syndrome” (RUS).

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“…In addition, donation after circulatory death (DCD) is increasingly practiced when brain-injured patients are deemed unlikely to enter brain death before withdrawal of life-sustaining therapy (2). In these cases, neurologists are typically consulted to confirm that meaningful recovery of brain function is futile, which requires proficiency in neuro-prognostication (3,4).…”

Section: Introductionmentioning

confidence: 99%

The Neurology of Death and the Dying Brain: A Pictorial Essay

Kondziella

2020

Front. Neurol.

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As neurologists earn their living with the preservation and restoration of brain function, they are also well-positioned to address the science behind the transition from life to death. This essay in pictures highlights areas of neurological expertise needed for brain death determination; shows pitfalls to avoid during the clinical examination and interpretation of confirmatory laboratory tests in brain death protocols; illustrates the great variability of brain death legislations around the world; discusses arguments for the implementation of donation after circulatory death (DCD); points to unresolved questions related to DCD and the time between cardiac standstill and organ procurement ("hands-off period"); provides an overview of the epidemiology and semiology of near-death experiences, including their importance for religion, literature, and the visual arts; suggests biological mechanisms for near-death experiences such as dysfunction of temporoparietal cortex, N-methyl-D-aspartate receptor antagonism, migraine aura, and rapid eye movement sleep; hypothesizes that thanatosis (aka. death-feigning, a common behavioral trait in the animal kingdom) represents the evolutionary origin of neardeath experiences; and speculates about the future implications of recent attempts of brain resuscitation in an animal model. The aim is to provide the reader with a thorough understanding that the boundaries within the neurology of death and the dying brain are being pushed just like everywhere else in the clinical neurosciences.

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Predicting the outcome of a comatose patient at the bedside

Cited by 7 publications

References 49 publications

Clinical Ethics Consultation in Neurology – a case series

Clinical Ethics Consultation in Neurology – a case series

Jahi McMath, a New Disorder of Consciousness

The Neurology of Death and the Dying Brain: A Pictorial Essay

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