Disorders of Consciousness
Disorders of Consciousness
A number of recent studies suggest that some 'vegetative state' patients have been misdiagnosed, judging by their ability to follow commands and in some cases even communicate through brain activity. Such studies highlight the difficulty in forming a diagnosis based only on behavioral assessments. We think that neuroimaging and electrophysiology methods will be used more frequently in clinical settings, integrated with existing behavioral assessments. Such efforts are expected to lead to a more accurate understanding of individual patients' cognitive abilities or even provide prognostic indicators. In terms of treatment planning (i.e., pain management and end-of-life decision-making), patients with disorders of consciousness are now offered the possibility of expressing their preferences by means of brain–computer interfaces. What remains to be clarified is the degree to which such indirect responses can be considered reliable and of legal representation.
It is not always easy to detect unambiguous signs of consciousness in patients with limited behavioral responses, such as coma survivors. Here, we aim to discuss the challenges that neurologists and assisting personnel are facing when dealing with patients with disorders of consciousness (DOC) in terms of diagnosis, prognosis and medical treatment. We will see that behavioral assessment remains the gold standard for diagnosing comatose, unresponsive ('vegetative') patients and patients in a minimally conscious state (MCS). Considering the persistence of diagnostic error in clinical evaluation, we highlight the need for objective biomarkers through neuroimaging and electrophysiological technologies. These technologies do not only assist clinicians in terms of differential diagnosis and potential prognosis, but also provide patients with muscle-independent means to communicate with their environment. For the moment, such technological advances remain experimental and require standardization if they are to be used in clinical routine. Importantly, clinical reality requires fast and valid assessments at the single-patient level. We foresee that an integrative approach of multimodal testing will shed light on the individual patient's pathophysiology and the underlying mechanisms. Eventually, new knowledge can lead to a redefinition of existing clinical taxonomies. Such advances are expected to lead to ethical and legal discussions, where patients' competency will potentially need to be re-established in a context of contemporary technology usage (e.g., by brain–computer interfaces), which allows them to express their wishes and even end-of-life preferences.
Abstract and Introduction
Abstract
A number of recent studies suggest that some 'vegetative state' patients have been misdiagnosed, judging by their ability to follow commands and in some cases even communicate through brain activity. Such studies highlight the difficulty in forming a diagnosis based only on behavioral assessments. We think that neuroimaging and electrophysiology methods will be used more frequently in clinical settings, integrated with existing behavioral assessments. Such efforts are expected to lead to a more accurate understanding of individual patients' cognitive abilities or even provide prognostic indicators. In terms of treatment planning (i.e., pain management and end-of-life decision-making), patients with disorders of consciousness are now offered the possibility of expressing their preferences by means of brain–computer interfaces. What remains to be clarified is the degree to which such indirect responses can be considered reliable and of legal representation.
Introduction
It is not always easy to detect unambiguous signs of consciousness in patients with limited behavioral responses, such as coma survivors. Here, we aim to discuss the challenges that neurologists and assisting personnel are facing when dealing with patients with disorders of consciousness (DOC) in terms of diagnosis, prognosis and medical treatment. We will see that behavioral assessment remains the gold standard for diagnosing comatose, unresponsive ('vegetative') patients and patients in a minimally conscious state (MCS). Considering the persistence of diagnostic error in clinical evaluation, we highlight the need for objective biomarkers through neuroimaging and electrophysiological technologies. These technologies do not only assist clinicians in terms of differential diagnosis and potential prognosis, but also provide patients with muscle-independent means to communicate with their environment. For the moment, such technological advances remain experimental and require standardization if they are to be used in clinical routine. Importantly, clinical reality requires fast and valid assessments at the single-patient level. We foresee that an integrative approach of multimodal testing will shed light on the individual patient's pathophysiology and the underlying mechanisms. Eventually, new knowledge can lead to a redefinition of existing clinical taxonomies. Such advances are expected to lead to ethical and legal discussions, where patients' competency will potentially need to be re-established in a context of contemporary technology usage (e.g., by brain–computer interfaces), which allows them to express their wishes and even end-of-life preferences.