NEW TAXONOMY FOR PROLONGED DISORDERS OF CONSCIOUSNESS MAY HELP WITH DECISIONS ON WITHDRAWAL OF CLINICALLY ASSISTED NUTRITION AND HYDRATION: A PROPOSED DECISION-MAKING PATHWAY

ABSTRACT: The number of patients surviving severe brain injury is increasing; however, many are left in a prolonged disorder of consciousness. With appropriate treatment, patients with prolonged disorders of consciousness can survive for years. Unless an advance directive exists, the treating clinicians can authorize withdrawal of clinically assisted nutrition and hydration for these patients, based on best interests. The classic terminology used in prolonged disorders of consciousness ranges from coma, vegetative state to minimally conscious state. However, a new group of patients with covert cognition has been identified in the last decade, making it necessary to revise the current taxonomy to better reflect our understanding of these conditions. With the introduction of a less ambiguous terminology, the challenges when it comes to withdrawal of clinically assisted nutrition and hydration of these patients may ease. A decisionmaking pathway for withdrawal of clinically assisted nutrition and hydration for patients with prolonged disorders of consciousness, based on a new taxonomy is proposed. These decisions should be based primarily on best interests. The adoption of a new classification for impairments of consciousness would clarify and improve how we think about these patients. Moreover, the development of accurate prognostic predictors would be a major step in the decision-making process, as it would influence the beneficent pathway towards the best clinical outcome. LAY ABSTRACT: The number of patients surviving severe brain injury is increasing; however, many are left in a prolonged disorder of consciousness. With appropriate treatment, these patients can survive for years. Unless a living will exists; the doctors can authorize withdrawal of artificial nutrition and hydration for these patients, based on best interests. There is an urge to revise the current terminology used in prolonged disorders of consciousness (vegetative state and minimally conscious state) to better reflect our understanding of these conditions, which will, in turn, ease the challenges faced when making a decision about withdrawal of artificial nutrition and hydration of these patients. A decision-making pathway based on a new taxonomy is proposed. The importance of reassessment is reinforced to clarify diagnosis and help with prognosis. Adopting a new classification for prolonged disorders of consciousness would clarify how we think about these patients.