Withdrawal of clinically assisted nutrition and hydration decisions in patients with prolonged disorders of consciousness: best interests of the patients and advance directives are the keys

Lejeune, N

doi:10.1136/medethics-2016-103813

Cited by 3 publications

(1 citation statement)

References 6 publications

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“…The majority of patients who move out of PDOC do so in the first year after the onset of their illness or injury. Furthermore, after 3 months for an anoxic aetiology and 12 months for a traumatic aetiology of the PDOC, it is known that the functional outcome will not be very different from the functional level to date ( 24 ). While it is not known how many patients will emerge after 12 months after injury, most patients in PDOC for this length of time remain severely or totally disabled ( 22 , 25 ).…”

Section: Diagnosis and Prognosismentioning

confidence: 99%

New taxonomy for prolonged disorders of consciousness may help with decisions on withdrawal of clinically assisted nutrition and hydration: A proposed decision-making pathway

Teixeira¹,

Rocha²,

Nunes³

2021

J Rehabil Med

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The number of patients surviving severe brain injury is increasing; however, many are left in a prolonged disorder of consciousness. With appropriate treatment, patients with prolonged disorders of consciousness can survive for years. Unless an advance directive exists, the treating clinicians can authorize withdrawal of clinically assisted nutrition and hydration for these patients, based on best interests. The classic terminology used in prolonged disorders of consciousness ranges from coma, vegetative state to minimally conscious state. However, a new group of patients with covert cognition has been identified in the last decade, making it necessary to revise the current taxonomy to better reflect our understanding of these conditions. With the introduction of a less ambiguous terminology, the challenges when it comes to withdrawal of clinically assisted nutrition and hydration of these patients may ease. A decisionmaking pathway for withdrawal of clinically assisted nutrition and hydration for patients with prolonged disorders of consciousness, based on a new taxonomy is proposed. These decisions should be based primarily on best interests. The adoption of a new classification for impairments of consciousness would clarify and improve how we think about these patients. Moreover, the development of accurate prognostic predictors would be a major step in the decision-making process, as it would influence the beneficent pathway towards the best clinical outcome. LAY ABSTRACT The number of patients surviving severe brain injury is increasing; however, many are left in a prolonged disorder of consciousness. With appropriate treatment, these patients can survive for years. Unless a living will exists; the doctors can authorize withdrawal of artificial nutrition and hydration for these patients, based on best interests. There is an urge to revise the current terminology used in prolonged disorders of consciousness (vegetative state and minimally conscious state) to better reflect our understanding of these conditions, which will, in turn, ease the challenges faced when making a decision about withdrawal of artificial nutrition and hydration of these patients. A decision-making pathway based on a new taxonomy is proposed. The importance of reassessment is reinforced to clarify diagnosis and help with prognosis. Adopting a new classification for prolonged disorders of consciousness would clarify how we think about these patients.

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Section: Diagnosis and Prognosismentioning

confidence: 99%

New taxonomy for prolonged disorders of consciousness may help with decisions on withdrawal of clinically assisted nutrition and hydration: A proposed decision-making pathway

Teixeira¹,

Rocha²,

Nunes³

2021

J Rehabil Med

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Using best interests meetings for people in a prolonged disorder of consciousness to improve clinical and ethical management

Wade

2017

J Med Ethics

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Current management of people with prolonged disorders of consciousness is failing patients, families and society. The causes include a general lack of concern, knowledge and expertise; a legal and professional framework which impedes timely and appropriate decision-making and/or enactment of the decision; and the exclusive focus on the patient, with no legitimate means to consider the broader consequences of healthcare decisions. This article argues that a clinical pathway based on the principles of (a) the English Mental Capacity Act 2005 and (b) using time-limited treatment trials could greatly improve patient management and reduce stress on families. There needs to be early and continuing use of formal best interests meetings, starting between 7 and 21 days after onset of unconsciousness (from any cause, including progressive disorders). The treatment options need to evolve as the clinical state and prognosis becomes more certain. A formal discussion of treatment withdrawal should occur when the upper bound of predicted recovery falls below a level the patient would have considered acceptable, and it should always be discussed when the condition is considered permanent. Any decision to stop treatment should be contingent on a formal second opinion from an independent expert who should review the clinical situation and expected prognosis, but not the best interests decision. The article also asks how, if at all, the adverse effects on the family and the resource implications of long-term care of people left in a prolonged state of unconsciousness should be incorporated in the process.

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Chapitre 30. États de conscience altérée : soins palliatifs et décisions de fin de vie

Erp¹,

Rohaut²,

Sanz³

et al. 2020

Manuel De Soins Palliatifs

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Withdrawal of clinically assisted nutrition and hydration decisions in patients with prolonged disorders of consciousness: best interests of the patients and advance directives are the keys

Cited by 3 publications

References 6 publications

New taxonomy for prolonged disorders of consciousness may help with decisions on withdrawal of clinically assisted nutrition and hydration: A proposed decision-making pathway

New taxonomy for prolonged disorders of consciousness may help with decisions on withdrawal of clinically assisted nutrition and hydration: A proposed decision-making pathway

Using best interests meetings for people in a prolonged disorder of consciousness to improve clinical and ethical management

Chapitre 30. États de conscience altérée : soins palliatifs et décisions de fin de vie

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