The potential ethical implications for goals of care discussions between surrogate decision makers and health care providers concerning patients who reside in a state of cognitive motor dissociation were investigated in this new study from a team at Columbia University and New York Presbyterian Hospital.
Fourteen to 15% of patients who have chronic and acute disorders of consciousness (DOC) also have cognitive motor dissociation (CMD), but predictions of long-term outcomes among this patient population remain hard to make.
“CMD is a state in which willful brain activation can be detected in the absence of behavioral evidence of command following,” study authors wrote, “and it has been associated with improved 12-month functional outcomes and is an independent predictor of time to functional recovery together.”
Findings from their investigation of the potential ethical implications for goals of care (GOC) discussions between surrogate decision makers and health care professionals (HCPs) concerning patients who reside in a state of CMD were presented at the American Academy of Neurology annual meeting. The authors also note that functional MRI and task-based EEG have shown potential to aid these discussions, but that level of acceptance of the technology for this purpose remains uncertain—despite recommendations to integrate CMD into recover predictions.
Adult patients who were in a coma, vegetative state, or minimally conscious state-minus; spoke English or Spanish as their first language; and did not have a preexisting DOC or neurological condition were included. Forty surrogate decision makers, 45 nurses, and 40 physicians/advanced practice providers (APPs; 3 attending, 16 fellow, and 15 resident physicians and 6 physician assistants or advanced practice registered nurses) participated. Most were female (61%, 73%, and 60%, respectively), and the most common race/ethnicities represented were Hispanic/Latino (45%) and Black or African American (24%) among surrogate decision makers, Asian (44%) and White (33%) among nurses, and White (48%) and Asian (40%) among the physicians/APPs. Religiosity was most, very, or fairly important among the surrogate decision makers and nurses and fairly or not important among the physicians/APPs.
Surveys were administered “and kept identical as much as possible to allow comparisons, with slight adjustments to reflect the unique relationship to the patient,” noted the authors, and close-ended questions gauged views on GOC decisions. Surrogate decision maker questions covered scenarios in which brain activity to commands measured by EEG or MRI was or was not detected.
Higher percentage of surrogates indicated that a CMD diagnosis would be helpful in decision-making overall and with improved recovery at 1 year compared with physicians: 92% vs 73% and 94% vs 84%, respectively. This gap closed quite a bite when clinical trial participation was queried. Fifty-six and 90% of surrogates would support clinical trial participation if CMD was not and was detected compared with 54% and 89% of HCPs, respectively.
As for changing their GOC if brain activity to commands was not detected, most replied this information would make them more likely to consider withdrawal of life sustaining treatment (WOLST), with 52% of surrogates, 89% of nurses, and 82% of physicians/APPs noting this decision vs 46%, 9%, and 18%, respectively, who would not change their care goals and 2%, 2%, and 0% who would be less likely to consider WOLST.
The detection of brain activity, however, would see more respondents being less likely to consider WOLST, with 54%, 47%, and 77% of surrogates, nurses, and physicians/APPs making this decision compared with 44%, 40%, and 21%, respectively, who would not change their care goals and 2%, 13%, and 3% who would be more likely to consider WOLST.
“CMD detection has been associated with long-term recovery,” the study investigators emphasized, “but its absence does not mean patients have a poor prognosis,” even though that absence being linked to more HCPs choosing WOLST “may present an opportunity for exacerbated cognitive biases during GOC discussions.”
“These results demonstrate acceptance of technology-supported prognostication amongst HCPs and surrogate decision makers,” they concluded. “Broadly, both groups indicate advanced brain imaging techniques would be helpful in making GOC decisions.”
They also note that their analysis highlights the importance of education when HCPs choose to use technology-supported prognostication for surrogate decision makers and HCPs and that “balancing encouraging information with the inherent uncertainty of prognostication will be important when guiding surrogate decision-making.”
Heinonen GA, Carmona JC, Doyle K, et al. Ethical implications of detecting cognitive motor dissociation early after brain injury. Presented at: AAN 2023; April 22-27, 2023; Boston, MA. Accessed April 25, 2023. https://cattendee.abstractsonline.com/meeting/10872/Presentation/7197