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Commentary on "Uncovering Awareness: Medical and Ethical Challenges in Diagnosing and Treating the Minimally Conscious State"
By Nicholas D. Schiff and Jerome B. Posner
 June 14, 2010

The techniques described in this article have revolutionized our thinking about brain-injured patients who appear to be unconscious. It has been known for a few years that some of these patients are, in fact, “minimally conscious.” The implications for patient care (analgesia, nutrition, communication) are enormous. Patients without consciousness do not benefit from attempts at communication or attempts to relieve discomfort, whereas many minimally conscious patients require such intervention. While we do not yet know how best to communicate with minimally conscious patients or have any evidence concerning their thinking and their emotions (Are they depressed? Would antidepressants help?), the techniques presented in the article promise solutions to these questions.

A caveat: The subjects of these studies have been almost exclusively head-injury patients, most of whom are young. What the situation is in the older patient who suffers unconsciousness from cardiac arrest or stroke remains to be discovered. Evidence from small observational cohort studies demonstrates that meaningful recovery (including outcomes significantly above severe disability) often occurs by 10 months after an injury in patients who are only minimally conscious three to four months after the injury.1,2 The potential for delayed recovery is not widely recognized, and that combines with the neuroimaging and electrophysiologic techniques discussed in the article to illustrate the need for significant changes in the evaluation of patients in ICU and other settings.

In addition, these results indicate that reassessment of patients in subacute and chronic care settings are warranted. At least two U.S. national panels have considered policy recommendations aimed at providing a structure for identifying patients who may recover but whose potential to do so might not be recognized. An Institute of Medicine exploratory meeting examined the need for a systematic study to address research in the area of disorders of consciousness and policy changes that may be required to advance the care of patients in light of evolving knowledge.3 A report to Congress by an interdisciplinary group of clinicians and researchers focused on developing joint research and clinical initiatives to establish standards of care for ongoing treatment and evaluation of patients with disorders of consciousness.4 Unfortunately, no systematic policy effort has been initiated to address this rapidly changing landscape and make adequate neurological assessment available to this vulnerable population.

Comments

Experience with minimally conscious state
Mary Laforet

6/14/2010 7:47:24 PM

I was unconscious 3 weeks after a car threw me into the car I was pushing. After 2 weeks in the ICU they must have been able to tell I was progressing and they moved me to private room. What I remember best is the tampering with the catheter and the tilt table. PAIN encourages consciousness, or at least it did for me. Over the years I have on occasion helped by volunteering at Magee Rehab in Phila, PA, and it makes me wonder if the bladder pain may have been a factor. A patient there was just staring out into space and I wondered if perhaps his bladder was cut to put a permanent catheter in, like they had wanted to do for me.

At the time my mother was a nurse in charge of a nursing pool. In her fledgling business, I was the 1st patient. I had round-the-clock nurses that helped with the catheter. My foot of course was of no use, as it dropped everytime I went to move. I managed to live my life in this deficient state until old-age began creeping in. My active lifestyle meant that although muscles had always compensated for those hurt in the TBI, that was no longer sufficient. I was in constant pain. But now I made it my business to learn the proper way to get the correct muscles working again.

This was all inspired by Obama asking a group of disabled veterans "Does any body know about this?"I wrote a book about that, called "Fighting Back." The publisher is Tate Publishing out of Mustang, OK. That first night in 1975 my parents were instructed to pray for my death. But through the years I have come to some concllusions about how to influence the brain and my book is worth reading. I'm doing a "pep-talk" Thursday at Special Tree rehabilitation to other survivors. I kindof feel robbed of my life. Now at almost 50, I understand and can relate to the difficulties of this and I can see that moving and getting back into life was the thing which saved me.

References

1. J. T. Giacino and K. Kalmar, “The Vegetative and Minimally Conscious States: A Comparison of Clinical Features and Functional Outcome,” Journal of Head Trauma Rehabilitation 12 (1997): 36–51.
 
2. M. H. Lammi et al., “The Minimally Conscious State and Recovery Potential: A Follow-up Study 2 to 5 Years After Traumatic Brain Injury,” Archives of Physical Medicine and Rehabilitation 86 (2005): 746–754.
 
3. J. J. Fins, N. D. Schiff, and K. M. Foley, “Late Recovery From the Minimally Conscious State: Ethical and Policy Implications,” Neurology 68, no. 4 (2007): 304–307.

4. J. Berube, J. J. Fins, J. T. Giacino, D. Katz, J. Langois, J. Whyte, and G. Zitnay, “The Mohonk Report: A Report to Congress on Disorders of Consciousness: Assessment, Treatment, and Research Needs” (Charlottesville, VA: National Brain Injury Research, Treatment, and Training Foundation, 2006), http://www.northeastcenter.com/the-mohonk-report-disorders-of-consciousness-assessment-treatment-research-needs.pdf.