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Ethics Corner: Prognosis and Disorders of Consciousness Dear Readers of the Ethics Corner: For this issue, we are using a different format, and we hope you find it interesting and useful. Instead of a case review, we will be discussing three recent publications in the field of bioethics and/or palliative care that might be of interest to members of the NCS. If you enjoy this format and wish to let us know, suggest articles, or if you want to tell us that you would rather return to the case-based format, please email me at michael.rubin@utsouthwestern.edu. Determination of prognosis in disorders of consciousness is one of the most challenging aspects of neurocritical care. We take heterogeneous populations of a particular type of neurologic insult and attempt to use elements of exam and statistical trends to predict what we think is going to happen for the long and short term. We take the human brain, arguable the most complex organ system in the natural world, and attempt to assign categorical variables to it. This is as ambitious of a project as asking a mathematician, “Take every number in an infinite set, and tell me which five are the most important.” Why would we do such a thing? Well, people must make decisions about goals of care, and they need our best guess in helping them decide. Trying to impose certainty on such variance leaves us giving recommendations such as “yes, definitely, there is a chance of recovery and he might wake up but I really think it is more likely he’ll be in a prolonged state of unconsciousness and debilitation living in a nursing home.” The more coercive might add “…where he will suffer from pressure ulcers and die of infectious complications.” Even worse is the practitioner who would say “he will never wake up, and I know this to be a fact.” Three recent publications offer interesting insight into this familiar conundrum, each with their own value. One study from Belgium offers new imaging data about the minimally consciousness state, published in Lancet Neurology. The second paper we will discuss is a review of disorders of consciousness and neuro ethics by Joseph Fins form the AMA Journal of Ethics, and the third paper is a collaboration of Jordon Bonomo, Claude Hemphill and myself regarding the dangers of prognosis and the self-fulfilling prophecy. Di Perri C, et al. Neural correlates of consciousness in patients who have emerged from a minimally conscious state: a cross-sectional multimodal imaging study. Lancet Neurology. 2016 Jul; 15(8):830-42. While the physics of fMRI and FDG-PET may be beyond the working knowledge of the average neuro intensivist (yours truly included), this paper offers an interesting comparison of MRI, fMRI and FDG-PET of normal controls, those that have emerged from a minimally conscious state, those in a minimally conscious state and those with unresponsive wakefulness syndrome. Features of brain metabolism and network connectivity have an appreciable variance correlating with level of consciousness. Advanced imaging studies portend a very useful future in helping distinguish the fine gradations of level of consciousness that will hopefully allow for more patient specific prognosis in disorders of consciousness. Fins, JJ. Neuroethics and Disorders of Consciousness: Discerning Brain States in Clinical Practice and Research. AMA Journal of Ethics. 2016 Dec;18(12):1182-1191. Dr. Fins continues his work in disorders of consciousness with his review of the origins of the vegetative state and how it relates to categories of brain injury. Furthermore, he discusses the fluid nature of vegetative states and how the literature supports that patients may recover into minimally conscious states. Lastly, he advocates for further research in patients in the minimally conscious state to better recognize what they can perceive as well as potential ways to elevate their level of consciousness. Rubin, M, Bonomo J, Hemphill JC. Intersection of Prognosis and Palliation in Neurocritical Care. Current Opinion in Critical Care. 2017 Feb 4 epub ahead of print. In this review, we explore three aspects of end-of-life care in the neuro ICU, all in the context of the self-fulfilling prophecy: prognostication, family discussions and the determination of death, including its relation to organ donation. The emphasis is on the importance of not pre-determining the outcome of any part of this process. Dr. Hemphill makes some profound points about the ICH score and how it could be misused in prognosticating recovery, contributing to the self-fulfilling prophecy. I offer some thoughts on end-of-life discussions including an emphasis on not letting the data that we do have on decision making preclude an open mind on how the process should flow. Additionally, suggestions on palliative care measures and duration of survival are discussed. Finally, Dr. Bonomo steps the reader through organ donation and the two paths that lead to the opportunity for a patient to donate. 27


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