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
- Neil Scolding, Adrian M Owen, John Keown.
Prolonged disorders of
consciousness: a critical evaluation of the new UK guidelines. Brain
2021 Jul 28;144(6):1655-1660.
doi: 10.1093/brain/awab063.