Disorders of consciousness in the ICU: gaps in establishing and communicating the prognosis

Survivorship of severe acute brain injuries is increasing worldwide, with many of these injuries resulting in disorders of consciousness (DOC). We aim to review current challenges in achieving goal-concordant care for patients with DOC, while highlighting recent advancements to guide neurologic prognostication.

Prognostic uncertainty, cognitive biases among clinicians and surrogate decision-makers (SDM), and a paucity of nuanced neurologic assessments in many settings pose major barriers to accurate prognostication. Short observation times and large variations in the use of life-sustaining treatments limit diagnosis and evaluation of prognostic tools. Multimodal assessments enhance prognostic accuracy but are vastly underutilized. Innovative neurodiagnostic techniques and dynamic modeling are currently limited by availability and lack of rigorous validation. There is a growing understanding of the complex needs of SDM and factors that impact communication of prognosis, ultimately determining care decisions.

Prognostic science may improve with newer neurodiagnostic technologies, but thoughtful validation and implementation is needed to limit perpetuation of methodological biases. Attention to cognitive errors in shared decision-making and efforts to enhance prognosis communication may improve goal-concordant decisions. A sharpened focus on the experiences of SDM and understanding the dyadic SDM-patient longitudinal outcomes is needed to guide goal-concordant decisions.