Assessment of Covert Consciousness in the Intensive Care Unit: Clinical and Ethical Considerations.

TitleAssessment of Covert Consciousness in the Intensive Care Unit: Clinical and Ethical Considerations.
Publication TypeJournal Article
Year of Publication2018
AuthorsEdlow, Brian L., and Fins Joseph J.
JournalJ Head Trauma Rehabil
Date Published2018 Nov/Dec
KeywordsBrain Injuries, Traumatic, Consciousness, Critical Care, Electroencephalography, Female, Humans, Intensive Care Units, Magnetic Resonance Imaging, Male, Middle Aged, Persistent Vegetative State, Prognosis, Withholding Treatment, Young Adult

OBJECTIVE: To propose a practical ethical framework for how task-based functional magnetic resonance imaging (fMRI) and electroencephalography (EEG) may be used in the intensive care unit (ICU) to identify covert consciousness in patients with acute severe traumatic brain injury (TBI).

METHODS: We present 2 clinical scenarios in which investigational task-based fMRI and EEG were performed in critically ill patients with acute severe TBI who appeared unconscious on the bedside behavioral assessment. From these cases, we consider the clinical and ethical challenges that emerge and suggest how to reconcile them. We also provide recommendations regarding communication with families about ICU patients with covert consciousness.

RESULTS: Covert consciousness was detected acutely in a patient who died in the ICU due to withdrawal of life-sustaining therapy, whereas covert consciousness was not detected in a patient who subsequently recovered consciousness, communication, and functional independence. These cases raise ethical challenges about how assessment of covert consciousness in the ICU might inform treatment decisions, prognostication, and perceptions about the benefits and burdens of ongoing care.

CONCLUSIONS: Given that covert consciousness can be detected acutely in the ICU, we recommend that clinicians reconsider evaluative norms for ICU patients. As our clinical appreciation of covert consciousness evolves and its ethical import unfolds, we urge prognostic humility and transparency when clinicians communicate with families in the ICU about goals of care.

Alternate JournalJ Head Trauma Rehabil
PubMed ID30395042
PubMed Central IDPMC6317885
Grant ListK23 NS094538 / NS / NINDS NIH HHS / United States

Weill Cornell Medicine Consortium for the Advanced Study of Brain Injury 520 East 70th Street New York, NY