Catholic Medical Quarterly Volume 71(4) November 2021

Prolonged disorders of consciousness: a critical evaluation of the new UK guidelines

Published in July 2021
A paper by  Neil  Scolding,  Adrian M Owen and John Keown stated that:

In July 2021 Neil Scolding, Adrian M Owen and John Keown published a paper which questioned the new UK guidelines on Prolonged Disorders of Consciousness. The paper expands upon the debate about how we manage people with what has often previously been known as Persistent Vegetative State. The authors highlight that consciousness is more common than you think and make a plea for more use of EEG and Functional MRI to work all this out. The abstract is reproduced below.

Abstract
In March 2020, the Royal College of Physicians in the UK published national guidelines on the management of patients with prolonged disorders of consciousness, updating their 2013 guidance ‘particularly in relation to recent developments in assessment and management and … changes in the law governing … the withdrawal of clinically assisted nutrition and hydration’. The report’s primary focus is on patients who could live for many years with treatment and care. This update, by a neurologist, an imaging neuroscientist, and a lawyer-ethicist, questions the document’s rejection of any significant role for neuroimaging techniques including functional MRI and/or bedside EEG to detect covert consciousness in such patients. We find the reasons for this rejection unconvincing, given (i) the significant advances made in the use of this technology in recent years; and (ii) the wider scope for its use envisaged by the earlier (2018) guidelines issued by the American Academy of Neurology. We suggest that, since around one in five patients diagnosed with prolonged disorders of consciousness are in fact conscious enough to follow commands in a neuroimaging context (i.e. those who are ‘covertly conscious’ or those with ‘cognitive motor dissociation’), and given the clinical, ethical and legal importance of determining whether patients with prolonged disorders of consciousness are legally competent or at least able to express their views and feelings, the guidance from the Royal College of Physicians requires urgent review.

We at  the CMQ would comment that this clearly matters. If people who  are conscious are  not being identified as such,  then   they  may  be deprived of care which  would be provided if they  are conscious.

On the other hand,  the concern we have about the ending of life by  withdrawing nutrition and hydration is not confined to  those who  are conscious.  People who  are unconscious should not be preventing from receiving clinically assisted nutrition and hydration either.

Dr Owen and colleagues questioned the national guidelines published by the Royal College of Physicians in the UK in March 2020. Those guidelines concerned the "management of patients with prolonged disorders of consciousness. The new guidelines updated the College's 2013 guidance".

The paper, which is written by a neurologist, an imaging neuroscientist, and a lawyer-ethicist, questions the College's rejection of any significant role for neuro imaging techniques including functional MRI and/or bedside EEG to detect covert consciousness in such patients.

They point out that they do not believe the reasoning behind the College's arguments given the

(i)            the significant advances made in the use of this technology in recent years; and
(ii)           the wider scope for its use envisaged by the earlier (2018) guidelines issued by the American Academy of Neurology.

The authors go on to suggest that "since around one in five patients diagnosed with prolonged disorders of consciousness are in fact conscious enough to follow commands in a neuro imaging context (i.e. those who are 'covertly conscious' or those with 'cognitive motor dissoci­ation'), and given the clinical, ethical and legalimportance of determining whether patients with prolonged disorders of consciousness are legally competent or at least able to express their views and feelings, the guidance from the Royal College of Physicians requires urgent review."

Reference