Chronic Disorders of Consciousness

  • Sunil KothariEmail author


Disorders of consciousness are neurological conditions characterized by severe alterations in the level of consciousness and include coma, vegetative state, and the minimally conscious state. Often a transient stage after severe acute brain injury, these states may persist for a subset of patients. Recently, there has been a significant growth in our understanding of persistent disorders of consciousness; clinicians should familiarize themselves with these recent developments in the areas of classification, assessment, prognosis, and treatment. This chapter reviews these developments with the aim of improving the provision of care that is medically appropriate and that maximizes the quality of life of patients and caregivers. For those patients for whom the withdrawal of treatment is considered, clinical and ethical issues that are particularly relevant to disorders of consciousness are discussed, so as to allow for a peaceful and dignified death.


Disorders of consciousness Traumatic brain injury Anoxic brain injury Vegetative state Minimally conscious state Prognostication Caregivers Goals of care Withdrawal of life support 


  1. 1.
    Fins JJ, Master MG, Gerber LM, Giacino JT. The minimally conscious state. Arch Neurol. 2007;64(10):1400.PubMedGoogle Scholar
  2. 2.
    Berube J, Fins JJ, Giacino JT, Katz D, Langois J, Whyte J, et al. The mohonk report: a report to congress on disorders of consciousness: assessment, treatment, and research needs. Charlottesville: National Brain Injury Research, Treatment, and Training Foundation; 2006.Google Scholar
  3. 3.
    Giacino JT, Fins JJ, Laureys S, Schiff ND. Disorders of consciousness after acquired brain injury: the state of the science. Nat Rev Neurol. 2014;10(2):99–114.PubMedGoogle Scholar
  4. 4.
    Posner JB, Saper CB, Schiff ND, Plum F. In: Gilman S, Herdman W, editors. Plum and posner’s diagnosis of stupor and coma. 4th ed. New York: Oxford University Press; 2007. 401 p.Google Scholar
  5. 5.
    Bagnato S, Boccagni C, Sant’Angelo A, Fingelkurts AA, Fingelkurts AA, Gagliardo C, et al. Long-lasting coma. Funct Neurol. 2014;29(3):201–5.PubMedPubMedCentralGoogle Scholar
  6. 6.
    Giacino JT, Kalmar K. Diagnostic and prognostic guidelines for the vegetative and minimally conscious states. Neuropsychol Rehabil. 2005;15(3–4):166–74.PubMedGoogle Scholar
  7. 7.
    Jennett B, Plum F. Persistent vegetative state after brain damage. A syndrome in search of a name. Lancet (London, England). 1972;1(7753):734–7.Google Scholar
  8. 8.
    Laureys S, Celesia GG, Cohadon F, Lavrijsen J, León-Carrión J, Sannita WG, et al. Unresponsive wakefulness syndrome: a new name for the vegetative state or apallic syndrome. BMC Med. 2010;8(1):68.PubMedPubMedCentralGoogle Scholar
  9. 9.
    Childs NL, Mercer WN, Childs HW. Accuracy of diagnosis of persistent vegetative state. Neurology. 1993;43(8):1465–7.PubMedGoogle Scholar
  10. 10.
    Andrews K, Murphy L, Munday R, Littlewood C. Misdiagnosis of the vegetative state: retrospective study in a rehabilitation unit. BMJ. 1996;313(7048):13–6.PubMedPubMedCentralGoogle Scholar
  11. 11.
    Schnakers C, Vanhaudenhuyse A, Giacino J, Ventura M, Boly M, Majerus S, et al. Diagnostic accuracy of the vegetative and minimally conscious state: clinical consensus versus standardized neurobehavioral assessment. BMC Neurol. 2009;9(1):35.PubMedPubMedCentralGoogle Scholar
  12. 12.
    Giacino JT, Schnakers C, Rodriguez-Moreno D, Kalmar K, Schiff N, Hirsch J. Behavioral assessment in patients with disorders of consciousness: gold standard or fool’s gold? Prog Brain Res. 2009;177:33–48.Google Scholar
  13. 13.
    Saddawi-Konefka D, Berg SM, Nejad SH, Bittner EA. Catatonia in the ICU. Crit Care Med. 2014;42(3):e234–41.PubMedGoogle Scholar
  14. 14.
    Majerus S, Bruno MA, Schnakers C, Giacino JT, Laureys S. The problem of aphasia in the assessment of consciousness in brain-damaged patients. Prog Brain Res. 2009;177:49–61.PubMedGoogle Scholar
  15. 15.
    Schnakers C, Bessou H, Rubi-Fessen I, Hartmann A, Fink GR, Meister I, et al. Impact of aphasia on consciousness assessment. Neurorehabil Neural Repair. 2015;29(1):41–7.PubMedGoogle Scholar
  16. 16.
    Seel RT, Sherer M, Whyte J, Katz DI, Giacino JT, Rosenbaum AM, et al. Assessment scales for disorders of consciousness: evidence-based recommendations for clinical practice and research. Arch Phys Med Rehabil. 2010;91(12):1795–813.PubMedGoogle Scholar
  17. 17.
    Giacino JT, Kalmar K. CRS-R Coma recovery scale-revised administration and scoring guidelines johnson rehabilitation institution affiliated with JFK Medical Center. Accessed on Jan 27, 2018.
  18. 18.
    Wannez S, Heine L, Thonnard M, Gosseries O, Laureys S. The repetition of behavioral assessments in diagnosis of disorders of consciousness. Ann Neurol. 2017;81(6):883–9.PubMedGoogle Scholar
  19. 19.
    Whyte J, DiPasquale MC. Assessment of vision and visual attention in minimally responsive brain injured patients. Arch Phys Med Rehabil. 1995;76(9):804–10.PubMedGoogle Scholar
  20. 20.
    Whyte J, DiPasquale MC, Vaccaro M. Assessment of command-following in minimally conscious brain injured patients. Arch Phys Med Rehabil. 1999;80(6):653–60.PubMedGoogle Scholar
  21. 21.
    Bekinschtein T, Leiguarda R, Armony J, Owen A, Carpintiero S, Niklison J, et al. Emotion processing in the minimally conscious state. J Neurol Neurosurg Psychiatry. 2004;75(5):788.PubMedPubMedCentralGoogle Scholar
  22. 22.
    Machado C, Korein J, Aubert E, Bosch J, Alvarez MA, Rodríguez R, et al. Recognizing a mother’s voice in the persistent vegetative state. Clin EEG Neurosci. 2007;38(3):124–6.PubMedGoogle Scholar
  23. 23.
    Perrin F, Castro M, Tillmann B, Luauté J. Promoting the use of personally relevant stimuli for investigating patients with disorders of consciousness. Front Psychol. 2015;6:1102.PubMedPubMedCentralGoogle Scholar
  24. 24.
    Jox RJ, Kuehlmeyer K, Klein A-M, Herzog J, Schaupp M, Nowak DA, et al. Diagnosis and decision making for patients with disorders of consciousness: a survey among family members. Arch Phys Med Rehabil. 2015;96(2):323–30.PubMedGoogle Scholar
  25. 25.
    Sattin D, Giovannetti AM, Ciaraffa F, Covelli V, Bersano A, Nigri A, et al. Assessment of patients with disorder of consciousness: do different coma recovery scale scoring correlate with different settings? J Neurol. 2014;261(12):2378–86.PubMedGoogle Scholar
  26. 26.
    Monti MM, Vanhaudenhuyse A, Coleman MR, Boly M, Pickard JD, Tshibanda L, et al. Willful modulation of brain activity in disorders of consciousness. N Engl J Med. 2010;362(7):579–89.PubMedGoogle Scholar
  27. 27.
    Kondziella D, Friberg CK, Frokjaer VG, Fabricius M, Møller K. Preserved consciousness in vegetative and minimal conscious states: systematic review and meta-analysis. J Neurol Neurosurg Psychiatry. 2016;87(5):485–92.PubMedGoogle Scholar
  28. 28.
    Bruno M-A, Vanhaudenhuyse A, Thibaut A, Moonen G, Laureys S. From unresponsive wakefulness to minimally conscious PLUS and functional locked-in syndromes: recent advances in our understanding of disorders of consciousness. J Neurol. 2011;258(7):1373–84.PubMedGoogle Scholar
  29. 29.
    Schiff ND. Cognitive motor dissociation following severe brain injuries. JAMA Neurol. 2015;72(12):1413.PubMedGoogle Scholar
  30. 30.
    Larson MD, Behrends M. Portable infrared pupillometry. Anesth Analg. 2015;120(6):1242–53.PubMedGoogle Scholar
  31. 31.
    Laeng B, Sirois S, Gredebäck G. Pupillometry. Perspect Psychol Sci. 2012;7(1):18–27.PubMedGoogle Scholar
  32. 32.
    Hartmann M, Fischer MH. Pupillometry: the eyes shed fresh light on the mind. Curr Biol. 2014;24(7):R281–2.PubMedGoogle Scholar
  33. 33.
    Stoll J, Chatelle C, Carter O, Koch C, Laureys S, Einhäuser W. Pupil responses allow communication in locked-in syndrome patients. Curr Biol. 2013;23(15):R647–8.PubMedGoogle Scholar
  34. 34.
    Bekinschtein TA, Coleman MR, Niklison J, Pickard JD, Manes FF. Can electromyography objectively detect voluntary movement in disorders of consciousness? J Neurol Neurosurg Psychiatry. 2008;79(7):826–8.PubMedGoogle Scholar
  35. 35.
    Habbal D, Gosseries O, Noirhomme Q, Renaux J, Lesenfants D, Bekinschtein TA, et al. Volitional electromyographic responses in disorders of consciousness. Brain Inj. 2014;28(9):1171–9.PubMedGoogle Scholar
  36. 36.
    Lesenfants D, Habbal D, Chatelle C, Schnakers C, Laureys S, Noirhomme Q. Electromyographic decoding of response to command in disorders of consciousness. Neurology. 2016;87(20):2099–107.PubMedGoogle Scholar
  37. 37.
    Monti MM. Cognition in the vegetative state. Annu Rev Clin Psychol. 2012;8(1):431–54.PubMedGoogle Scholar
  38. 38.
    Hauger SL, Schanke A-K, Andersson S, Chatelle C, Schnakers C, Løvstad M. The clinical diagnostic utility of electrophysiological techniques in assessment of patients with disorders of consciousness following acquired brain injury. J Head Trauma Rehabil. 2017;32(3):185–96.PubMedGoogle Scholar
  39. 39.
    Owen AM. Using functional magnetic resonance imaging and electroencephalography to detectconsciousness after severe brain injury. Handb Clin Neurol. 2015;127:277–93.PubMedGoogle Scholar
  40. 40.
    Harrison AH, Connolly JF. Finding a way in: a review and practical evaluation of fMRI and EEG for detection and assessment in disorders of consciousness. Neurosci Biobehav Rev. 2013;37(8):1403–19.PubMedGoogle Scholar
  41. 41.
    Guldenmund P, Stender J, Heine L, Laureys S. Mindsight: diagnostics in disorders of consciousness. Crit Care Res Pract. 2012;2012:624724.PubMedPubMedCentralGoogle Scholar
  42. 42.
    Morlet D, Fischer C. MMN and novelty P3 in coma and other altered states of consciousness: a review. Brain Topogr. 2014;27(4):467–79.PubMedGoogle Scholar
  43. 43.
    Kirschner A, Cruse D, Chennu S, Owen AM, Hampshire A. A P300-based cognitive assessment battery. Brain Behav. 2015;5(6):e00336.PubMedPubMedCentralGoogle Scholar
  44. 44.
    Casali AG, Gosseries O, Rosanova M, Boly M, Sarasso S, Casali KR, et al. A theoretically based index of consciousness independent of sensory processing and behavior. Sci Transl Med. 2013;5(198):198ra105.PubMedGoogle Scholar
  45. 45.
    Casarotto S, Comanducci A, Rosanova M, Sarasso S, Fecchio M, Napolitani M, et al. Stratification of unresponsive patients by an independently validated index of brain complexity. Ann Neurol. 2016;80(5):718–29.PubMedPubMedCentralGoogle Scholar
  46. 46.
    Napolitani M, Bodart O, Canali P, Seregni F, Casali A, Laureys S, et al. Transcranial magnetic stimulation combined with high-density EEG in altered states of consciousness. Brain Inj. 2014;28(9):1180–9.PubMedGoogle Scholar
  47. 47.
    Schiff ND. Multimodal neuroimaging approaches to disorders of consciousness. J Head Trauma Rehabil. 2006;21(5):388–97.PubMedGoogle Scholar
  48. 48.
    Coleman MR, Bekinschtein T, Monti MM, Owen AM, Pickard JD. A multimodal approach to the assessment of patients with disorders of consciousness. Prog Brain Res. 2009;177:231–48.PubMedGoogle Scholar
  49. 49.
    Pistoia F, Sacco S, Sarà M, Carolei A. The perception of pain and its management in disorders of consciousness. Curr Pain Headache Rep. 2013;17(11):374.PubMedGoogle Scholar
  50. 50.
    Schnakers C, Zasler N. Assessment and management of pain in patients with disorders of consciousness. PM&R. 2015;7(11):S270–7.Google Scholar
  51. 51.
    Schnakers C, Chatelle C, Demertzi A, Majerus S, Laureys S. What about pain in disorders of consciousness? AAPS J. 2012;14(3):437–44.PubMedPubMedCentralGoogle Scholar
  52. 52.
    Chatelle C, Thibaut A, Whyte J, De Val MD, Laureys S, Schnakers C. Pain issues in disorders of consciousness. Brain Inj. 2014;28(9):1202–8.PubMedGoogle Scholar
  53. 53.
    Pistoia F, Sacco S, Stewart J, Sarà M, Carolei A. Disorders of Consciousness: Painless or Painful Conditions?—Evidence from Neuroimaging Studies. Brain Sciences. 2016;6(4):47.PubMedCentralGoogle Scholar
  54. 54.
    Margetis K, Korfias SI, Gatzonis S, Boutos N, Stranjalis G, Boviatsis E, et al. Intrathecal baclofen associated with improvement of consciousness disorders in spasticity patients. Neuromodulation Technol Neural Interf. 2014;17(7):699–704.Google Scholar
  55. 55.
    Pistoia F, Sacco S, Sarà M, Franceschini M, Carolei A. Intrathecal baclofen: effects on spasticity, pain, and consciousness in disorders of consciousness and locked-in syndrome. Curr Pain Headache Rep. 2015;19(1):466.PubMedGoogle Scholar
  56. 56.
    Oyama H, Kito A, Maki H, Hattori K, Tanahashi K. Consciousness recovery induced by intrathecal baclofen administration after subarachnoid hemorrhage -two case reports. Neurol Med Chir (Tokyo). 2010;50(5):386–90.Google Scholar
  57. 57.
    Sarà M, Pistoia F, Mura E, Onorati P, Govoni S. Intrathecal baclofen in patients with persistent vegetative state: 2 hypotheses. Arch Phys Med Rehabil. 2009;90(7):1245–9.PubMedGoogle Scholar
  58. 58.
    Keenan MA, Esquenazi A, Mayer NH. Surgical treatment of common patterns of lower limb deformities resulting from upper motoneuron syndrome. Adv Neurol. 2001;87:333–46.PubMedGoogle Scholar
  59. 59.
    Giacino JT, Kalmar K. The vegetative and minimally conscious states: a comparison of clinical features and functional outcome. J Head Trauma Rehabil. 1997;12(4):36–51.Google Scholar
  60. 60.
    Estraneo A, Moretta P, Loreto V, Lanzillo B, Santoro L, Trojano L. Late recovery after traumatic, anoxic, or hemorrhagic long-lasting vegetative state. Neurology. 2010;75(3):239–45.PubMedGoogle Scholar
  61. 61.
    Luaute J, Maucort-Boulch D, Tell L, Quelard F, Sarraf T, Iwaz J, et al. Long-term outcomes of chronic minimally conscious and vegetative states. Neurology. 2010;75(3):246–52.PubMedGoogle Scholar
  62. 62.
    Greenwald BD, Hammond FM, Harrison-Felix C, Nakase-Richardson R, Howe LLS, Kreider S. Mortality following traumatic brain injury among individuals unable to follow commands at the time of rehabilitation admission: a National Institute on Disability and Rehabilitation Research traumatic brain injury model systems study. J Neurotrauma. 2015;32(23):1883–92.PubMedGoogle Scholar
  63. 63.
    The Multi-Society Task Force on PVS. Medical aspects of the persistent vegetative state. N Engl J Med. 1994;330(21):1499–508.Google Scholar
  64. 64.
    Childs NL, Mercer WN. Late improvement in consciousness after post-traumatic vegetative state. N Engl J Med. 1996;334(1):24–5.PubMedGoogle Scholar
  65. 65.
    Voss HU, Uluğ AM, Dyke JP, Watts R, Kobylarz EJ, McCandliss BD, et al. Possible axonal regrowth in late recovery from the minimally conscious state. J Clin Invest. 2006;116(7):2005–11.PubMedPubMedCentralGoogle Scholar
  66. 66.
    Katz DI, Polyak M, Coughlan D, Nichols M, Roche A. Natural history of recovery from brain injury after prolonged disorders of consciousness: outcome of patients admitted to inpatient rehabilitation with 1–4 year follow-up. Prog Brain Res. 2009;177:73–88.PubMedGoogle Scholar
  67. 67.
    Nakase-Richardson R, Whyte J, Giacino JT, Pavawalla S, Barnett SD, Yablon SA, et al. Longitudinal outcome of patients with disordered consciousness in the NIDRR TBI model systems programs. J Neurotrauma. 2012;29(1):59–65.PubMedGoogle Scholar
  68. 68.
    Nakase-Richardson R, Tran J, Cifu D, Barnett SD, Horn LJ, Greenwald BD, et al. Do rehospitalization rates differ among injury severity levels in the NIDRR traumatic brain injury model systems program? Arch Phys Med Rehabil. 2013;94(10):1884–90.PubMedGoogle Scholar
  69. 69.
    Howell K, Grill E, Klein A-M, Straube A, Bender A. Rehabilitation outcome of anoxic-ischaemic encephalopathy survivors with prolonged disorders of consciousness. Resuscitation. 2013;84(10):1409–15.PubMedGoogle Scholar
  70. 70.
    Kothari S, DiTommaso C. Prognosis after severe traumatic brain injury: a practical, evidence-based approach. In: Zasler N, Katz D, Zafonte R, Arciniegas D, Bullock M, Kreutzer J, editors. Brain injury medicine: principles and practice. 2nd ed. New York: Demos Medical Publishing; 2012. p. 248–78.Google Scholar
  71. 71.
    Bruno M-A, Gosseries O, Ledoux D, Hustinx R, Laureys S. Assessment of consciousness with electrophysiological and neurological imaging techniques. Curr Opin Crit Care. 2011;17(2):146–51.PubMedGoogle Scholar
  72. 72.
    Wijnen VJM, Eilander HJ, de Gelder B, van Boxtel GJM. Repeated measurements of the auditory oddball paradigm is related to recovery from the vegetative state. J Clin Neurophysiol. 2014;31(1):65–80.PubMedGoogle Scholar
  73. 73.
    Steppacher I, Eickhoff S, Jordanov T, Kaps M, Witzke W, Kissler J. N400 predicts recovery from disorders of consciousness. Ann Neurol. 2013;73(5):594–602.PubMedGoogle Scholar
  74. 74.
    Xu W, Jiang G, Chen Y, Wang X, Jiang X. Prediction of minimally conscious state with somatosensory evoked potentials in long-term unconscious patients after traumatic brain injury. J Trauma Inj Infect Crit Care. 2012;72(4):1024–30.Google Scholar
  75. 75.
    Cavinato M, Freo U, Ori C, Zorzi M, Tonin P, Piccione F, et al. Post-acute P300 predicts recovery of consciousness from traumatic vegetative state. Brain Inj. 2009;23(12):973–80.PubMedGoogle Scholar
  76. 76.
    Qin P, Di H, Yan X, Yu S, Yu D, Laureys S, et al. Mismatch negativity to the patient’s own name in chronic disorders of consciousness. Neurosci Lett. 2008;448(1):24–8.PubMedGoogle Scholar
  77. 77.
    Wijnen VJM, van Boxtel GJM, Eilander HJ, de Gelder B. Mismatch negativity predicts recovery from the vegetative state. Clin Neurophysiol. 2007;118(3):597–605.PubMedGoogle Scholar
  78. 78.
    Daltrozzo J, Wioland N, Mutschler V, Kotchoubey B. Predicting coma and other low responsive patients outcome using event-related brain potentials: a meta-analysis. Clin Neurophysiol. 2007;118(3):606–14.PubMedGoogle Scholar
  79. 79.
    Vogel D, Markl A, Yu T, Kotchoubey B, Lang S, Müller F. Can mental imagery functional magnetic resonance imaging predict recovery in patients with disorders of consciousness? Arch Phys Med Rehabil. 2013;94(10):1891–8.PubMedGoogle Scholar
  80. 80.
    Sarà M, Pistoia F, Pasqualetti P, Sebastiano F, Onorati P, Rossini PM. Functional isolation within the cerebral cortex in the vegetative state. Neurorehabil Neural Repair. 2011;25(1):35–42.PubMedGoogle Scholar
  81. 81.
    Fins JJ. Rights come to mind: brain injury, ethics, and the struggle for consciousness. New York: Cambridge University Press; 2015. 379 p.Google Scholar
  82. 82.
    Fins JJ, Wright MS, Kraft C, Rogers A, Romani MB, Godwin S, et al. Whither the “Improvement Standard”? Coverage for severe brain injury after Jimmo v Sebelius. J Law Med Ethics. 2016;44(1):182–93.PubMedGoogle Scholar
  83. 83.
    Ciurleo R, Bramanti P, Calabrò RS. Pharmacotherapy for disorders of consciousness: are “Awakening” drugs really a possibility? Drugs. 2013;73(17):1849–62.PubMedGoogle Scholar
  84. 84.
    Mura E, Pistoia F, Sara M, Sacco S, Carolei A, Govoni S. Pharmacological modulation of the state of awareness in patients with disorders of consciousness: an overview. Curr Pharm Des. 2013;999(999):5–6.Google Scholar
  85. 85.
    Oliveira L, Fregni F. Pharmacological and electrical stimulation in chronic disorders of consciousness: new insights and future directions. Brain Inj. 2011;25(4):315–27.PubMedGoogle Scholar
  86. 86.
    Giacino JT, Whyte J, Bagiella E, Kalmar K, Childs N, Khademi A, et al. Placebo-controlled trial of amantadine for severe traumatic brain injury. N Engl J Med. 2012;366(9):819–26.PubMedGoogle Scholar
  87. 87.
    Martin RT, Whyte J. The effects of methylphenidate on command following and yes/no communication in persons with severe disorders of consciousness. Am J Phys Med Rehabil. 2007;86(8):613–20.PubMedGoogle Scholar
  88. 88.
    Pistoia F, Sara M, Sacco S, Franceschini M, Carolei A. Silencing the brain may be better than stimulating it. The GABA effect. Curr Pharm Des. 2013;999(999):23–4.Google Scholar
  89. 89.
    Whyte J, Rajan R, Rosenbaum A, Katz D, Kalmar K, Seel R, et al. Zolpidem and restoration of consciousness. Am J Phys Med Rehabil. 2014;93(2):101–13.PubMedGoogle Scholar
  90. 90.
    Thonnard M, Gosseries O, Demertzi A, Lugo Z, Vanhaudenhuyse A, Bruno M-A, et al. Effect of zolpidem in chronic disorders of consciousness: a prospective open-label study. Funct Neurol. 2013;28(4):259–64.PubMedGoogle Scholar
  91. 91.
    Ragazzoni A, Cincotta M, Giovannelli F, Cruse D, Young GB, Miniussi C, et al. Clinical neurophysiology of prolonged disorders of consciousness: from diagnostic stimulation to therapeutic neuromodulation. Clin Neurophysiol. 2017;128(9):1629–46.PubMedGoogle Scholar
  92. 92.
    Estraneo A, Pascarella A, Moretta P, Masotta O, Fiorenza S, Chirico G, et al. Repeated transcranial direct current stimulation in prolonged disorders of consciousness: a double-blind cross-over study. J Neurol Sci. 2017;375:464–70.PubMedGoogle Scholar
  93. 93.
    Thibaut A, Bruno M-A, Ledoux D, Demertzi A, Laureys S. tDCS in patients with disorders of consciousness: sham-controlled randomized double-blind study. Neurology. 2014;82(13):1112–8.PubMedGoogle Scholar
  94. 94.
    Angelakis E, Liouta E, Andreadis N, Korfias S, Ktonas P, Stranjalis G, et al. Transcranial direct current stimulation effects in disorders of consciousness. Arch Phys Med Rehabil. 2014;95(2):283–9.PubMedGoogle Scholar
  95. 95.
    Pape TL-B, Rosenow J, Lewis G. Transcranial magnetic stimulation: a possible treatment for TBI. J Head Trauma Rehabil. 2006;21(5):437–51.PubMedGoogle Scholar
  96. 96.
    Piccione F, Cavinato M, Manganotti P, Formaggio E, Storti SF, Battistin L, et al. Behavioral and neurophysiological effects of repetitive transcranial magnetic stimulation on the minimally conscious state: a case study. Neurorehabil Neural Repair. 2011;25(1):98–102.PubMedGoogle Scholar
  97. 97.
    Schiff ND, Giacino JT, Kalmar K, Victor JD, Baker K, Gerber M, et al. Behavioural improvements with thalamic stimulation after severe traumatic brain injury. Nature. 2007;448(7153):600–3.PubMedGoogle Scholar
  98. 98.
    Schiff ND. Moving toward a generalizable application of central thalamic deep brain stimulation for support of forebrain arousal regulation in the severely injured brain. Ann N Y Acad Sci. 2012;1265(1):56–68.PubMedGoogle Scholar
  99. 99.
    Shah SA, Schiff ND. Central thalamic deep brain stimulation for cognitive neuromodulation – a review of proposed mechanisms and investigational studies. Eur J Neurosci. 2010;32(7):1135–44.PubMedPubMedCentralGoogle Scholar
  100. 100.
    Corazzol M, Lio G, Lefevre A, Deiana G, Tell L, André-Obadia N, et al. Restoring consciousness with vagus nerve stimulation. Curr Biol. 2017;27(18):R994–6.PubMedGoogle Scholar
  101. 101.
    Kitzinger J, Kitzinger C. The “window of opportunity” for death after severe brain injury: family experiences. Sociol Health Illn. 2013;35(7):1095–112.PubMedGoogle Scholar
  102. 102.
    Giovannetti AM, Covelli V, Sattin D, Leonardi M. Caregivers of patients with disorder of consciousness: burden, quality of life and social support. Acta Neurol Scand. 2015;132(4):259–69.PubMedGoogle Scholar
  103. 103.
    Bayne T, Hohwy J, Owen AM. Are there levels of consciousness? Trends Cogn Sci. 2016;20(6):405–13.PubMedGoogle Scholar
  104. 104.
    Soeterik SM, Connolly S, Playford ED, Duport S, Riazi A. The psychological impact of prolonged disorders of consciousness on caregivers: a systematic review of quantitative studies. Clin Rehabil. 2017;31(10):1374–85.PubMedGoogle Scholar
  105. 105.
    Covelli V, Sattin D, Giovannetti AM, Scaratti C, Willems M, Leonardi M. Caregiver’s burden in disorders of consciousness: a longitudinal study. Acta Neurol Scand. 2016;134(5):352–9.PubMedGoogle Scholar
  106. 106.
    Pagani M, Giovannetti AM, Covelli V, Sattin D, Raggi A, Leonardi M. Physical and mental health, anxiety and depressive symptoms in caregivers of patients in vegetative state and minimally conscious state. Clin Psychol Psychother. 2014;21(5):420–6.PubMedGoogle Scholar
  107. 107.
    Cruzado JA, Elvira de la Morena MJ. Coping and distress in caregivers of patients with disorders of consciousness. Brain Inj. 2013;27(7–8):793–8.PubMedGoogle Scholar
  108. 108.
    Leonardi M, Giovannetti AM, Pagani M, Raggi A, Sattin D, on behalf of the National Consortiu. Burden and needs of 487 caregivers of patients in vegetative state and in minimally conscious state: results from a national study. Brain Inj. 2012;26(10):1201–10.PubMedGoogle Scholar
  109. 109.
    Racine E. Pragmatic neuroethics: the social aspects of ethics in disorders of consciousness. Handb Clin Neurol. 2013;118:357–72.PubMedGoogle Scholar
  110. 110.
    Johnson LSM. Inference and inductive risk in disorders of consciousness. AJOB Neurosci. 2016;7(1):35–43.Google Scholar
  111. 111.
    Meisel A, Cerminara KL, Pope TM. Right to die: the law of end-of-life decisionmaking. 3rd ed. New York: Wolters Kluwer Legal & Regulatory; 2004.Google Scholar
  112. 112.
    Buckley T, Crippen D, DeWitt AL, Fisher M, Liolios A, Scheetz CL, et al. Ethics roundtable debate: withdrawal of tube feeding in a patient with persistent vegetative state where the patients wishes are unclear and there is family dissension. Crit Care. 2004;8(2):79–84.PubMedPubMedCentralGoogle Scholar
  113. 113.
    Lo B, Dornbrand L, Wolf LE, Groman M. The wendland case—withdrawing life support from incompetent patients who are not terminally ill. N Engl J Med. 2002;346(19):1489–93.PubMedGoogle Scholar
  114. 114.
    Towner H. In re Martin. Issues Law Med. 1996;12(3):267–71.PubMedGoogle Scholar
  115. 115.
    Johnson LSM. The right to die in the minimally conscious state. J Med Ethics. 2011;37(3):175–8.PubMedGoogle Scholar
  116. 116.
    Savulescu J, Kahane G. Brain damage and the moral significance of consciousness. J Med Philos. 2009;34(1):6–26.PubMedPubMedCentralGoogle Scholar
  117. 117.
    Gipson J, Kahane G, Savulescu J. Attitudes of lay people to withdrawal of treatment in brain damaged patients. Neuroethics. 2014;7(1):1–9.PubMedGoogle Scholar
  118. 118.
    Dworkin R. Life’s dominion: an argument about abortion, euthanasia, and individual freedom. New York: Vintage Books; 1994. 273 p.Google Scholar
  119. 119.
    Dresser R. Dworkin on dementia: elegant theory, questionable policy. Hast Cent Rep. 1995;25(6):32.Google Scholar
  120. 120.
    Kothari S. Clinical (mis)judgments of quality of life after disability. J Clin Ethics. 2004;15(4):300–7.PubMedGoogle Scholar
  121. 121.
    Kothari S, Kirschner KL. Abandoning the golden rule: the problem with “Putting Ourselves in the Patient’s Place”. Top Stroke Rehabil. 2006;13(4):68–73.PubMedGoogle Scholar
  122. 122.
    Fins JJ. Mosaic decisionmaking and reemergent agency after severe brain injury. Camb Q Healthc Ethics. 2018;27(1):163–74.PubMedGoogle Scholar
  123. 123.
    Fins JJ. Affirming the right to care, preserving the right to die: disorders of consciousness and neuroethics after Schiavo. Palliat Support Care. 2006;4(2):169–78.PubMedGoogle Scholar
  124. 124.
    Creutzfeldt CJ, Longstreth WT, Holloway RG. Predicting decline and survival in severe acute brain injury: the fourth trajectory. BMJ. 2015;351:h3904.PubMedPubMedCentralGoogle Scholar
  125. 125.
    Giacino JT, Kalmar K, Whyte J. The JFK Coma recovery scale-revised: measurement characteristics and diagnostic utility 1 1 No commercial party having a direct financial interest in the results of the research supporting this article has or will confer a benefit upon the authors or upon any organization with which the authors are associated. Arch Phys Med Rehabil. 2004;85(12):2020–9. Accessed on January 27, 2018.PubMedGoogle Scholar
  126. 126.
    Chatelle C, et al. Is the nociception coma scale-revised a useful clinical tool for managing pain in patients with disorders of consciousness? Clin J Pain. 2016;32(4):322.Google Scholar

Copyright information

© Springer International Publishing AG, part of Springer Nature 2019

Authors and Affiliations

  1. 1.Department of Physical Medicine and Rehabilitation, Baylor College of MedicineTIRR-Memorial Hermann HospitalHoustonUSA

Personalised recommendations