Use of serial standardised neurobehavioural assessment measures is recommended to improve diagnostic accuracy
Misdiagnosis and medical complications are common in the management of patients suffering from prolonged DoC, interfering with treatment and hindering recovery.2 In light of recent studies,3 it is recommended that once medically stable, patients with prolonged DoC be referred to a specialised setting for care by a team of multidisciplinary rehabilitation specialists (Level B). Use of serial standardised neurobehavioural assessment measures, such as those endorsed by the ACRM, is recommended to improve diagnostic accuracy (Level B). Prior to performing these assessments, it is recommended to attempt to increase arousal (Level B). Any confounding conditions should be identified and treated before establishing a diagnosis (Level B). When diagnostic ambiguity remains, specialised functional neuroimaging or electrophysiological procedures may differentiate MCS from VS/UWS (Level C).
“chronic VS” should replace “permanent VS”, along with a description of the current duration of VS/UWS
Given that some patients with prolonged DoC can achieve significant late functional recovery,4,5 it is recommended that clinicians avoid using language that suggests an overall poor prognosis (Level A) and that the term “permanent VS” no longer be used (Level B). It is recommended that the term “chronic VS” should replace “permanent VS”, along with a description of the current duration of VS/UWS. Use of serial standardised behavioural assessments is recommended to improve diagnosis and prognosis (Level B), while structural MRI, SPECT and CRS-R, as recommended, can help determine prognosis (Level B). Family counselling should also highlight that MCS (versus VS/UWS) and injury of a traumatic (versus non-traumatic) aetiology are associated with more favourable outcomes and that prognosis is not universally poor (Level B). Once a prognosis is determined, counselling should also encourage family members to establish goals of care and plan for a prolonged recovery (Level A), and should encompass the need for and type of long-term supportive care (Level B).
administration of an antiviral, antiparkinson drug between 4 and 16 weeks after injury is recommended to reduce time to recovery and the level of disability
Early identification of patient and family preferences is recommended to help guide the decision-making process; these preferences should also be considered throughout the care of the patient (Level A). Given the high rates of medical complications for patients with prolonged DoC, particularly in the first few months, it is recommended that clinicians remain vigilant and use a systematic approach to the diagnosis and treatment of these (Level B). Regardless of the level of consciousness, pain should be assessed and treated when it is suspected that a patient is suffering (Level B). Based on the results of a randomised controlled trial,6,7 administration of an antiviral, antiparkinson drug between 4 and 16 weeks after injury is recommended to reduce time to recovery and the level of disability (Level B). Families should be counselled about the limitations of proposed new treatment options, as many carry significant risks and often lack sufficient evidence to support their effectiveness (Level B).
the natural history and prognosis of children with prolonged DoC is not well defined
As for adults, recommendations for the care of children with prolonged DoC advocate for the treatment of confounding conditions and increasing arousal before performing diagnostic assessments, and for the use of serial standardised behavioural assessment (Level B). Families should be counselled that the natural history and prognosis of children with prolonged DoC is not well defined (Level B), that there are no current established evaluations to improve prognostic accuracy and there are no recognised therapies (Level B).