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Using best interests meetings for people in a prolonged disorder of consciousness to improve clinical and ethical management
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  • Published on:
    Best interests in early Prolonged Disorders of Consciousness: different balances
    • John A Gorst, Consultant Intensivist Morriston Hospital, Swansea

    Professor Wade’s article is an excellent overview of how to apply best interests to decision making in prolonged Disorders of Consciousness (PDoC) and should be mandatory reading for all health professionals caring for individuals with brain injuries1. However it fails, as does the Royal College of Physicians PDoC guidance, to adequately emphasise the vastly different balances when comparing withdrawal or withholding of clinically assisted artificial nutrition and hydration versus far more invasive and burdensome treatments.

    A significant proportion of patients in a PDOC are only alive because they were subjected to the very invasive life sustaining treatment that modern medicine can inflict. The existence of the clinical entity of PDoC could arguably be seen as a failure of prognostication and best interests decisions during the acute phase of a catastrophic brain injury; continuing invasive treatment that is arguably either ‘futile’, not in the patients best interests or be so invasive and prolonged to be disproportionate to the likely outcome2. However prognostication can be a difficult and uncertain at this stage.

    In our institution we admit up to 70 patients per annum who have sustained an out of hospital cardiac arrest and the majority of these survive long enough to need to assessment of neurological prognosis. At 72 hours, if the patient remain neurologically obtunded, we use multi-modal assessment to assess the likely outcome according to internation...

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    Conflict of Interest:
    None declared.
  • Published on:
    Caveats in the management of prolonged disorders of consciousness
    • Piotr Szawarski, Consultant in Intensive Care Medicine Wexham Park Hospital
    • Other Contributors:
      • Rebecca Agnew, Solicitor

    Dear Editor,

    We would like to congratulate Dr Derick T Wade on the article advocating a formalised approach to best interest meetings for people suffering from prolonged disorders of consciousness (1). It is a bold and pragmatic approach, borne out of his extensive experience, which will undoubtedly be of use to the practicing clinicians in the concerned jurisdiction. We are writing to supplement it with a few points which we consider worthy of additional noting.

    Firstly, we are glad of the title using the term “prolonged disorder of consciousness” given that persistent vegetative state (PVS) and minimally conscious state (MCS) are problematic from phenomenological and practical points of view. As Dr Wade notes, the two are difficult to differentiate and in practice permanence takes significant and possibly indeterminate time to establish. Unfortunately, the Law maintains a distinction between the two founded in the leading case of Anthony Bland. Abolishing the distinction would in practice prevent splitting hairs over what is likely to be an equally tragic outcome for the individual concerned, and the surviving relatives. From a legal and philosophical point of view, it can be argued, as it was in the Bland case, that patients in PVS lack any “best interests”. To quote Lord Mustill – “The distressing truth which must not be shirked, is that the proposed conduct is not in the best interests of Anthony Bland, for he has no best interests of any kind” – ackno...

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    Conflict of Interest:
    None declared.