Assessing emergence from a prolonged disorder of consciousness: Current opinion and practice in the UK

Abstract

Background: A patient in a prolonged disorder of consciousness (PDOC) is currently required to demonstrate functional object use or functional communication to be considered to have emerged from this state. A range of tasks and stimuli are used in assessment and patients are expected to achieve 100% accuracy. As consciousness is considered to occur along a continuum, determining emergence is not straightforward. Objective:To establish the opinions of expert clinicians on the criteria and tasks recommended for determining emergence from PDOC, and how emergence is determined in practice. This will identify current issues and define objectives for further research.Methods: A 31 item pilot-tested survey was distributed electronically to multidisciplinary teams working in post-acute specialist rehabilitation settings across the UK. Survey items included questions on diagnosis and confidence, informal assessment, formal assessment, and family involvement. Descriptive statistics were used to analyse responses to closed questions. Participant responses to open questions were analysed using thematic analysis (Braun & Clarke, 2006).Results: One hundred clinicians from a range of professions completed the survey. Approximately a third of respondents (30.4 %) used tasks other than those recommended by Giacino et al. (2002) and the Royal College of Physicians Guidelines (RCP, 2013) to determine emergence. A lack of confidence in the current tasks used to specifically detect the return of functional communication was reported by 46.4% of respondents. The majority of respondents (78.6%) reported that they worked with patients who they considered to have emerged, but who were unable to demonstrate emergence based on the current criteria. There was differing frequency in use of recommended tasks to identify functional communication: 100% used yes/no tasks, 88.9% used discrimination tasks, and 55.6% used matching tasks. A range of different stimuli were employed, but 30.6% of respondents were not confident that they were able to choose stimuli appropriately. Respondents reported a Conclusion: This study highlights the difficulties encountered by experienced clinicians in the UK when using the current recommended tasks and criteria to determine when a patient has emerged from PDOC. Accurate assessment and diagnosis are vital as they provide information about prognosis and influence decisions about ongoing care and rehabilitation. It would be beneficial to review the emergence criteria and determine which tasks and stimuli are most appropriate for assessment.

Efficacy of non-invasive brain stimulation for disorders of consciousness: a systematic review and meta-analysis

“…DoC refers to the loss of consciousness caused by various severe brain injuries; the mechanisms involved may be related to severe structural damage in the brain, thus causing widespread regression of excitatory synaptic activity and changes in the concentration of key biochemical substances such as local transmitters ( Clauss, 2014 ). If this condition extends for more than 28 days, it is known as prolonged disorders of consciousness (pDoC) ( Pundole et al, 2021 ). Currently, the rehabilitation of DoC patients remains a worldwide conundrum and involves a long and difficult rehabilitation cycle.…”