Prolonged disorders of consciousness: a critical evaluation of the new UK guidelines

Abstract

Earlier this year, the Royal College of Physicians in the UK published national guidelines on the management of patients with prolonged disorders of consciousness, updating their 2013 guidance ‘particularly in relation to recent developments in assessment and management and … changes in the law governing … the withdrawal of clinically assisted nutrition and hydration’. The report’s primary focus is on patients who could live for many years with treatment and care. This update, by a neurologist, an imaging neuroscientist, and a lawyer-ethicist, questions the document’s rejection of any significant role for neuroimaging techniques including functional MRI and/or bedside EEG to detect covert consciousness in such patients. We find the reasons for this rejection unconvincing, given (i) the significant advances made in the use of this technology in recent years; and (ii) the wider scope for its use envisaged by the earlier (2018) guidelines issued by the American Academy of Neurology. We suggest that, since around one in five patients diagnosed with prolonged disorders of consciousness are in fact conscious enough to follow commands in a neuroimaging context (i.e. those who are ‘covertly conscious’ or those with ‘cognitive motor dissociation’), and given the clinical, ethical and legal importance of determining whether patients with prolonged disorders of consciousness are legally competent or at least able to express their views and feelings, the guidance from the Royal College of Physicians requires urgent review.

Flowchart for Implementing Advanced Imaging and Electrophysiology in Patients With Disorders of Consciousness

“…Indeed, these technologies have been shown capable of detecting conscious awareness in patients appearing unresponsive in gold standard neurobehavioral assessments. 5-8 The recognition of the potential of these techniques is thus part of a broader agenda of increased evidence-based competency in assessing patients with DOC embraced and encouraged by both guidelines (as a notable exception, the RCP guidelines currently suggest employing AIEs in the context of research protocols only, and not in routine clinical practice; see reference 9 for a critical appraisal of this position).…”

Neuroethics across the Disorders of Consciousness Care Continuum

“…This is often due to lack of clarity about who is responsible for holding these discussions, especially when there is more than one doctor involved." 142,143 Despite the strength of national guidelines on preventing clinical nihilism, there is a looming worry that recommendations could be adopted unevenly across health centers. Consider the role of neuroimaging, as recommended in the AAN/ACRM/NIDILRR guideline.…”

Statistical learning in patients in the minimally conscious state

“…Prolonged disorders of consciousness (DoC) are defined as any disorder of consciousness that has continued for at least four weeks following sudden onset brain injury, includes patients in coma, VS/UWS, and MCS [42,43]. It is established that high level, covert cognition may be present in patients whose bedside evaluation appears consistent with the vegetative state or minimally conscious state [44][45][46].…”