Bernat on Ethical Issues in the Treatment of Severe Brain Injury
Posted May 05 2009 5:01pm
In a recent issue of the Annals of the NY Academy of Sciences, Dartmouth neurologist James L. Bernat has a fantastically superb article titled “Ethical Issues in the Treatment of Severe Brain Injury.”
He explains the different diagnoses in patients with severe brain injury: (i) brain death, (ii) coma, (iii) vegetative state, (iv) minimally conscious state, and (v) locked-in syndrome. He explains how the diagnoses should be made and describes the sources and types of error. There are three basic sources of error. First, physicians do not employ accepted testing techniques. Second, prognosis is inherently statistical and must be extrapolated to a particular patient. Third, the general statistics are skewed by the self-fulfilling prophesy (e.g. patients with large intracerebral hemorrhages often die but perhaps only because physicians think they will anyway and treat them less aggressively). No wonder there is significant surrogate distrust relating to prognostication.
Bernat then covers: (i) the management of clinical uncertainty, (ii) surrogate consent and refusal, (iii) shared decision making, and (iv) advance care planning. He ends by discussing rehabilitation options such as stimulation treatment, especially for MCS. And he discusses how functional neuroimaging modalities (like fMRI) will contribute to the accuracy of diagnosis and prognosis. Highly recommended.