Disorders of Consciousness Following Severe Brain Injury

This chapter reviews the diagnostic classification of disorders of consciousness, severe brain injuries that span a spectrum of brain states ranging from coma to the vegetative and minimally conscious states. The chapter makes the key point that brain states can-and do-evolve over time and that it is critical to be vigilant of changes that indicate that a patient who was unconscious is now conscious, albeit minimally so. The chapter describes how this traditional nosology is being challenged, and refined, by emergent technologies like neuroimaging and the ethical implications of this evolution for clinical practice and research. Specifically, the chapter addresses the challenge posed by discordant assessments when the clinical examination is brought into question by neuroimaging data that suggests that the patient is operating at a higher functional status than indicated by purely behavioral measures of assessment. Finally, drawing upon in-depth interviews of families touched by disorders of consciousness, the chapter explores family experiences and expectations, and suggests that these data indicates that the overriding goal of care, as understood by families, is the restitution of functional communication for this population silenced, at least in part, by disorders of consciousness.