Abstract
Consciousness defines our humanity more than any other biologic phenomena that a clinician
might be called upon to examine, diagnose, or treat. When family comes to the bedside
of a patient, they hope to find them talking, thinking, and feeling. The complexity
of consciousness allows an expansive gradation of dysfunction such that we must consider
numerous potential insults, possible interventions, and often an unknown likelihood
of recovery. As value-laden questions are more often in the hands of surrogate decision
makers, the neurologist is given the herculean task of not only diagnosing and treating
alterations of consciousness but also predicting the likely course of the disease
to empower surrogates to make a choice most consistent with the preferences of the
patient. The degree of uncertainty in the diagnosis and prognosis demands that the
clinician consider the ethics of the diagnosis, treatment, and prognostication of
disorders of consciousness. Expectations of acute and chronic care, the extent of
the formal neurological investigation, the potential of therapeutic trials, the self-fulfilling
prophecy that can occur with prognostication, and the challenges of shared decision
making are all subjects that we explore.
Keywords
ethics - prognostication - devastating brain injury - disorders of consciousness -
coma - vegetative state
