| Coma & Chronic Disorders of Consciousness  

Discontinuation of artificial nutrition and hydration and covert cognition

The process of end-of-life decision-making for patients with disorders of consciousness should include caregivers in bedside assessments and integrate advanced diagnostic brain imaging techniques when available. Controlled studies on pain perception during withdrawal of artificial nutrition and hydration are needed.

Van Erp and coauthors (1) reported a comprehensive care trajectory of persons with prolonged disorders of consciousness and the possible vicious circle of their outcomes. The topic of clinical misdiagnosis, the utility of a specific assessment by means of Coma Recovery Scale-Revised, and advanced diagnostic techniques were only briefly addressed, as well as the inclusion of caregivers in the evaluation of responsiveness, whereas it should be of paramount importance, especially in end of life decision-making and discontinuation of artificial nutrition and hydration (ANH).

The authors appropriately reported the use of midazolam and morphine during ANH withdrawal, although there are scarce data available on pain perception during ANH withdrawal and on the use of advanced diagnostic techniques and specific clinical tools such as Nociception Coma Scale, also with personalized painful stimulation (2). The aim of this letter is twofold:

 -To promote the inclusion of caregivers in the bedside behavioural assessment of persons with disorders of consciousness and to use diagnostic advanced techniques to ascertain or exclude the presence of covert cognition during ANH decision-making.

-To advocate controlled studies on pain perception by means of advanced diagnostic techiques during ANH withdrawal, to assess issues of pain and suffering.

 

Key Points:

  • Caregivers should be involved in bedside behavioural assessment of patients with disorders of consciousness
  • Advanced diagnostic techniques should be used to ascertain the presence of covert cognitive processing before the decision to discontinue artificial nutrition and hydration
  • Controlled studies on pain perception during withdrawal of artificial nutrition and hydration are required

 

References:

Formisano, R., & Zasler, N. (2020). Discontinuation of artificial nutrition and hydration and covert cognition. Brain Injury, 34(8), 1135-1135.

 

  1. van Erp WS, Lavrijsen JCM, Vos PE, Laureys S, Koopmans RT. Unresponsive wakefulness syndrome: outcomes from a vicious circle. Ann Neurol. 2019 Jan;1–7. doi:10.1002/ana.25624; https://pubmed.ncbi.nlm.nih.gov/31675139/
  2. Formisano R, Contrada M, Aloisi M, Ferri G, Schiattone S, Iosa M, Buzzi MG. Nociception Coma Scale with personalized painful stimulation versus standard stimulus in non-communicative patients with disorders of consciousness. Neuropsychological Rehabil. 2019 May;10:1–2. doi.org/10.1080/09602011.2019.1614464; https://pubmed.ncbi.nlm.nih.gov/31088203/
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