Ethical implications of detecting cognitive motor dissociation early after brain injury
Gregory Heinonen1, Jerina Carmona1, Kevin Doyle1, Lauren Grobois1, Lucie Kruger1, Angela Velasquez1, Athina Vrosgou1, Qi Shen1, Lizbeth Cespedes2, Mariam Yazdi2, Shivani Ghoshal1, David Roh1, Sachin Agarwal1, Soojin Park1, Lydia Dugdale3, Jan Claassen1
1Department of Neurology, Columbia University Irving Medical Center, 2New York Presbyterian Hospital, 3Center for Clinical Medical Ethics, Department of Medicine, Columbia University Vagelos College of Physicians & Surgeons
Objective:
To determine the impact of cognitive motor disassociation (CMD) in goals of care (GOC) decisions for surrogate decision makers and healthcare professionals (HCPs) of unconscious patients and assess support for clinical research participation.
Background:
Predictions of recovery from acute disorders of consciousness are imprecise but novel diagnostic tools are emerging. CMD refers to the detection of willful brain activation following motor commands in the absence of behavioral command following as detected by machine learning-supported EEG or MRI analysis. This phenomenon has been identified as a predictor of long-term recovery but acceptance of technology-supported prognostication by surrogates and HCPs remains uncertain.
Design/Methods:
We recruited surrogates and HCPs caring for unconscious patients with intracerebral hemorrhage. All participants completed a thirteen-item survey that captured data on demographics, education, religiosity, support for research participation, and receptiveness to technology-assisted prognostication in decision-making.
Results:
A total of 134 participants completed the survey, including 85 HCPs (40 physicians/PAs, 45 RNs) and 49 surrogates. There were no differences in sex between the two groups (67% of HCPs and 61% of surrogates were female). Surrogates reported stronger religious affiliation with 73% indicating religion was “very important” or “the most important part” of their life vs. 29% of HCPs. Both surrogates (73%) and HCPs (93%) indicated a diagnosis of CMD would help in decision-making. There was broad support for clinical trial participation in surrogates (86%) and HCPs (89%). HCPs were more likely than surrogates to change their goals if CMD could not be detected (OR 5.5, 95%-CI 2.4-12.7, p=0.00005). There was only a trend for a higher chance of HCPs to change their goals if CMD could be detected when compared to surrogates (OR 1.9, 95%-CI 0.9-3.8, p=0.08).
Conclusions:
These results demonstrate acceptance of technology-supported prognostication amongst HCPs and surrogate decision-makers. Targeted education to interpret detection and failure of detection of CMD is needed.