Ethics and the 2018 Practice Guideline on Disorders of Consciousness

Abstract

Abstract:The 2018 practice guideline on disorders of consciousness marks a seminal turning point in the care of patients with severe brain injury. As clinicians and health systems implement the guideline in practice, several ethical challenges will arise in assessing the benefits, harms, feasibility, and cost of recommended interventions. We provide guidance for clinicians when interpreting these recommendations and call on professional societies to develop an ethical framework to complement the guideline as it is implemented in clinical practice.

Toward Uniform Insurer Coverage for Functional MRI Following Severe Brain Injury

“…Risk of goal-discordant care is heightened if likely outcomes of treatment approaches are uncertain or overlooked. To the extent that fMRI could reduce this cone of uncertainty by clarifying a patient's current state of consciousness and likelihood of recovery, goal-concordant, responsible care will be safeguarded through its utilization 2…”

“…Such uncertainties generate vexing dilemmas surrounding continuation or cessation of life-sustaining therapies, approaches to analgesia, prognostication, and stewardship of resources, especially in resource-limited settings. The potential for misguided management decisions for a patient with severe brain injury increases with the level of uncertainty about that patient's state of consciousness and rehabilitation potential, especially when such uncertainty is avoided or unseen 1–3. A patient mistakenly assumed to be unconscious despite harboring covert awareness may be at increased risk of harm if therapies are withheld on the basis of misplaced futility judgments; conversely, a person whose likelihood of recovery is overestimated is prone to goal-discordant interventions, potentially prolonging suffering in a current or future state that might be considered by that person to be unacceptable.…”

Ethical Considerations in Neuroprognostication Following Acute Brain Injury

“…These recommendations confront the prevailing nihilism of clinicians caring for these patients. [45][46][47][48] Additionally, they promote a minimum period before offering a prognosis after ABI and underscore the importance of utilizing caution when neuroprognosticating, especially in the acute phase of injury. 45,46 However, the verbiage surrounding neuroprognostication guidance was left vague, perpetuating the possibility for clinician bias to influence prognosis and subsequent care and management decisions.…”

Ethical Guidance for Neuroprognostication in Disorders of Consciousness

“…In this issue of Neurology ® , Peterson and colleagues 9 sought to complement the guideline by providing direction on how to frame such nonuniversal statements of prognosis. In particular, Peterson et al 9 focus on terms that imply value: benefits, harms, feasibility, and costs that allow for individual clinical judgment during implementation. For benefits and harms, they focus on "prognostic pessimism."…”

“…In this issue of Neurology ®, Peterson and colleagues 9 sought to complement the guideline by providing direction on how to frame such nonuniversal statements of prognosis. In particular, Peterson et al 9 focus on terms that imply value: benefits, harms, feasibility, and costs that allow for individual clinical judgment during implementation. For benefits and harms, they focus on “prognostic pessimism.” They allude to the well-recognized “disability paradox,“ 10 urging clinicians to avoid pessimism and conflation with quality of life assessments and to be particularly mindful of how this is discussed in family meetings.…”