A systematic and evidence-based approach to clinical management of patients with disorders of consciousness

Abstract

Disorders of consciousness include coma, the vegetative state, the mini- mally conscious state and the post-traumatic confusional state. These conditions exist along a two-dimensional continuum comprised of arousal (i.e., wakefulness) and awareness (i.e., recognition of self and environment). Accurately characterizing and distinguishing these disorders early after onset is critically important as diagnosis is closely linked to prognosis and drives clinical decision-making. Unfortunately, published rates of misdiag- nosed consistently approach 40 % with most of the error accounted for by failure to detect consciousness when it is preserved. Misdiagnosis may limit access to medical and rehabilitation services and lead to premature with- drawal of life-sustaining care. In this chapter, we describe a systematic, evidence-based framework for clinical management of patients with DoC. The primary aim is to demonstrate how a standardized, multi-tiered approach to assessment organized around a structured "care map" can be instituted in the rehabilitation setting to inform diagnostic, prognostic and treatment decisions, ultimately improving the consistency and effectiveness of care.