Hostname: page-component-586b7cd67f-gb8f7 Total loading time: 0 Render date: 2024-11-22T09:49:11.996Z Has data issue: false hasContentIssue false

Practical Implications of the Minimally Conscious State Diagnosis in Adults

Published online by Cambridge University Press:  22 September 2017

Abstract:

This article addresses questions surrounding the minimally conscious state (MCS) from the perspective of adult clinical ethics. It describes the background of the MCS diagnosis, analyzes phenomenological ambiguities inherent in the nature of MCS, and raises epistemological concerns surrounding its diagnosis. It argues that in many cases, the burdens of prolonging treatment for people who have sustained certain severe brain injuries (SBI) outweigh the benefits, even if they are in or have the prospect of entering into MCS. It also argues that often such long-term measures are problematic from the perspective of patient preferences and stewardship of resources. Consequently, it suggests that the delineation of MCS as a distinct neurological state, along with research that seeks to expand how MCS is diagnosed, poses ethical difficulties for families and providers making decisions for affected patients.

Type
Articles
Copyright
Copyright © Cambridge University Press 2017 

Access options

Get access to the full version of this content by using one of the access options below. (Log in options will check for institutional or personal access. Content may require purchase if you do not have access.)

References

Notes

1. Ashwal, S, Cranford, R, Bernat, JL, Celesia, G, Coulter, D, Eisenberg, H, et al. Medical aspects of the persistent vegetative state, part I. New England Journal of Medicine 1994;330:1499–508.Google Scholar

2. See note 1, Ashwal et al. 1994.

3. Jennet B, Plum F. Persistent vegetative state after brain damage. A syndrome in search of a name. Lancet 1972;1:734–7.

4. See note 1, Ashwal et al. 1994.

5. See note 1, Ashwal et al. 1994.

6. Giacino, JT, Ashwal, S, Childs, N, Cranford, R, Jennett, B, Katz, DI, et al. The minimally conscious state: Definition and diagnostic criteria. Neurology 2002;58(3):349–53.CrossRefGoogle ScholarPubMed

7. See note 6, Giacino et al. 2002.

8. Schiff, ND, Ribary, U, Moreno, DR, Beattie, B, Kronberg, E, Blasberg, R, et al. Residual cerebral activity and behavioural fragments can remain in the persistently vegetative brain. Brain 2002;125(Pt 6):1210–34.CrossRefGoogle ScholarPubMed

9. Owen, AM, Coleman, MR, Boly, M, Davis, MH, Laureys, S, Pickard, JD. Detecting awareness in the vegetative state. Science 2006;313(5792):1402.CrossRefGoogle Scholar

10. Schiff, ND, Giacino, JT, Fins, JJ. Deep brain stimulation, neuroethics, and the minimally conscious state: moving beyond proof of principle. Archives of Neurology 2009;66(6):697702 CrossRefGoogle Scholar

11. Demertzi, A, Ledoux, D, Bruno, MA, Vanhaudenhuyse, A, Gosseries, O, Soddu, A, et al. Attitudes towards end–of-life issues in disorders of consciousness: A European survey. Journal of Neurology 2011;258(6):1058–65.CrossRefGoogle Scholar

12. See note 3, Jennet, Plum 1972.

13. See note 3, Jennet, Plum 1972.

14. American Academy of Neurology. Position of the American academy of neurology on certain aspects of the care and management of the persistent vegetative state patient. Neurology 1989;39:125–6.CrossRefGoogle ScholarPubMed

15. President’s Commission for the Study of Ethical Problems in Medicine and Biomedical and Behavioral Research. Deciding to Forego Life-Sustaining Treatment A Report on the Ethical, Medical, and Legal Issues in Treatment Decisions. Washington, DC: U. S. Government Printing Office [GPO], March 1983.Google Scholar

16. See note 1, Ashwal et al. 1994.

17. See note 6, Giacino et al. 2002.

18. Fins, JJ. Rights Come to Mind: Brain Injury, Ethics, and the Struggle for Consciousness. New York: Cambridge University Press; 2015.CrossRefGoogle ScholarPubMed

19. See note 6, Giacino et al. 2002.

20. See note 6, Giacino et al. 2002.

21. See note 6, Giacino et al. 2002.

22. See note 9, Owen et al. 2006.

23. Boly, M, Faymonville, ME, Peigneux, P, Lambermont, B, Damas, P, Del Fiore, G, et al. Auditory processing in severely brain injured patients: differences between the minimally conscious state and the persistent vegetative state. Archives of Neurology 2004;61(2):233–8.CrossRefGoogle ScholarPubMed

24. See note 23, Boly et al. 2004.

25. See note 23, Boly et al. 2004.

26. See note 23, Boly et al. 2004.

27. See note 9, Owen et al. 2006.

28. Coleman, MR, Davis, MH, Rodd, JM, Robson, T, Ali, A, Owen, AM, et al. Towards the routine use of brain imaging to aid the clinical diagnosis of disorders of consciousness. Brain 2009;132(9):2541–52.CrossRefGoogle ScholarPubMed

29. Fins, JJ. Constructing an ethical stereotaxy for severe brain injury: Balancing risks, benefits and access. Nature Reviews Neuroscience 2003;4(2)323–7.CrossRefGoogle Scholar

30. See note 9, Owen et al. 2006.

31. See note 9, Owen et al. 2006.

32. See note 9, Owen et al. 2006.

33. Eklund A, Thomas EN, Knutsson H. Cluster failure: Why fMRI inferences for spatial extent have inflated false-positive rates Proceedings of the National Academy of Sciences 2016;2016:02413.

34. See note 9, Owen et al. 2006.

35. Owen, AM, Coleman, MR. Detecting awareness in the vegetative state. Annals of the New York Academy of Science 2008;1129:130–8.CrossRefGoogle ScholarPubMed

36. Jennett, B. The vegetative state. Journal of Neurology, Neurosurgery & Psychiatry 2002;73:355–7CrossRefGoogle ScholarPubMed

37. Block, N. On a confusion about the function of consciousness. Behavioral and Brain Sciences 1995;18:227–47.CrossRefGoogle Scholar

38. Weiskrantz, L. Blindsight revisited. Current Opinion in Neurobiology 1996;6(2):215–20.CrossRefGoogle ScholarPubMed

39. McDowell, J. The content of perceptual experience. The Philosophical Quarterly 1994;44(175):190205.CrossRefGoogle Scholar

40. Brewer, B. Perception and Reason. Oxford: Oxford University Press; 1999.Google Scholar

41. Gallagher, S. Philosophical conceptions of the self: implications for cognitive science. Trends in Cognitive Sciences 2000;4(1):1421.CrossRefGoogle ScholarPubMed

42. Kon, AA, Shepard, EK, Sederstron, NO, Swoboda, SM, Marshal, MF, Birriel, B, et al. Defining futility and potentially inappropriate interventions: a policy statement from the Society of Critical Care Medicine Ethics Committee. Critical Care Medicine 2016;44(9):1769.CrossRefGoogle ScholarPubMed

43. See note 42, Kon et al. 2016.

44. Sharma K, Stevens RD. Determinants of prognosis in neurocatastrophes. Handbook of Clinical Neurology 2017;379–95.

45. MRC CRASH Trial Collaborators, Perel P, Arango M, Clayton T, Edwards P, Komolafe E, et al. Predicting outcome after traumatic brain injury: practical prognostic models based on large cohort of international patients. BMJ 2008;336(7641):425–9.

46. Sandel, ME. Medical management of the comatose, vegetative, or minimally responsive patient/ NeuroRehabilitation 1996;6(1):917.CrossRefGoogle Scholar

47. Demertzi, A, Schnakers, C, Ledoux, D, Chatelle, C, Bruno, MA, Vanhaudenhuyse, A, et al. Different beliefs about pain perception in the vegetative and minimally conscious states: a European survey of medical and paramedical professionals. Progress in Brain Research 2009;177:329–38.CrossRefGoogle ScholarPubMed

48. See note 47, Demertzi, et al. 2009.

49. Boly, M, Faymonville, ME, Schnakers, C, Peigneux, P, Lambermont, B, Phillips, C, et al. Perception of pain in the minimally conscious state with PET activation: An observational study. The Lancet Neurology 2008;7(11):1013–20.CrossRefGoogle Scholar

50. Jennett, B. Resource allocation for the severely brain damaged. Archives of Neurology 1976;33(9):595–7.CrossRefGoogle Scholar

51. Demertzi, A, Ledoux, D, Bruno, MA, Vanhaudenhuyse, A, Gosseries, O, Soddu, A, et al. Attitudes towards end-of-life issues in disorders of consciousness: a European survey. Journal of Neurology 2011;258(6):1058–65.CrossRefGoogle ScholarPubMed

52. This is a European study, which may affect the represented attitudes.

53. Strauss, DJ, Ashwal, S, Day, SM, Shavelle, RM. Life expectancy of children in vegetative and minimally conscious states. Pediatric Neurology 2000;23(4):312–9.CrossRefGoogle ScholarPubMed

54. Pisa, FE, Biasutti, E, Drigo, D, Barbone, F. The prevalence of vegetative and minimally conscious states: a systematic review and methodological appraisal. The Journal of Head Trauma Rehabilitation 2014;29(4):E23–30.CrossRefGoogle ScholarPubMed

55. See note 29, Fins 2003.

56. Yoder S. The coming nursing home shortage. The Fiscal Times, January 26, 2012; available at http://khn.org/news/fiscal-times-nursing-home-shortage/ (last accessed 28 Feb 2017).

57. See note 56, Yoder 2012.

58. Beck L, Landon G. Anticipating changes in regional demand for nursing homes. Public Policy Institute of California, 2016; available at http://www.ppic.org/main/publication_quick.asp?i=1217 (last accessed 28 Feb 2017).

59. Sabatini J. Report: San Francisco faces skilled-nursing bed shortage. SF Examiner, February 19, 2016; available at http://www.sfexaminer.com/report-san-francisco-faces-skilled-nursing-bed-shortage/ (last accessed 28 Feb 2017).

60. Harrington, C, Olney, B, Carrillo, H, Kang, T. Nurse staffing and deficiencies in the largest for-profit nursing home chains and chains owned by private equity companies. Health Services Research 2012;47(1 Pt 1):106–28.CrossRefGoogle ScholarPubMed

61. Juraschek, SP, Zhang, X, Ranganathan, V, Lin, VW. United States registered nurse workforce report card and shortage forecast. American Journal of Medical Quality 2012;27(3):241–9.CrossRefGoogle ScholarPubMed

62. Tran, BT. Reduced ICU bed availability is associated with worse outcomes on the general wards. Critical Care Alert 2014;22(6):41–42.Google Scholar

63. Orsini, J, Blaak, C, Yeh, A, Fonseca, X, Helm, T, Butala, A, et al. Triage of patients consulted for ICU admission during times of ICU-bed shortage. Journal of Clinical Medicine Research 2014;6(6):463.Google ScholarPubMed

64. See note 9, Owen et al. 2006.

65. Stern, JM, Sazbon, L, Becker, E, Costeff, H. Severe behavioral disturbance in families of patients with prolonged coma. Brain Injury 1988;2(3):259–62.CrossRefGoogle Scholar

66. Chiambretto, P, Ferrario, SR, Zotti, AM. Patients in a persistent vegetative state: Caregiver attitudes and reactions. Acta Neurologica Scandinavica 2001;104(6):364–8.CrossRefGoogle Scholar

67. Healthtalk. Family Experiences of Vegetative and Minimally Conscious States. September 2014; available at http://www.healthtalk.org/peoples-experiences/nerves-brain/family-experiences-vegetative-and-minimally-conscious-states/topics (last accessed 28 Feb 2017).