Abstract
Pain and suffering in persons with disorders of consciousness (DoC) remain poorly understood, frequently unaddressed or inadequately addressed, and controversial on numerous levels. This narrative literature review will address a number of critical issues germane to pain and suffering in this challenging group of patients, providing an introductory overview of the topic, perspectives on current knowledge regarding pain pathoanatomy and pathophysiology, and a review of common pain generators and factors that can lead to the chronifcation of pain. Caveats on bedside pain assessment challenges, as well as electrophysiologic and neuroimaging findings in these patients, will also be explored. Pain management techniques, including non-pharmacological and pharmacological, will be reviewed. Ethical considerations in the context of pain and suffering in persons with disorders of consciousness will round out the review prior to our concluding comments.
Highlights
In the practice of medicine, pain is often encountered consequential to disease and/or acquired brain injuries
As noted by Fins and Bernat [110], all clinicians should advocate for routine universal pain precautions in the context of neuropalliative care given the potential for the presence of covert consciousness [75,76,77]
It is of common clinical experience that persons with disorders of consciousness (DoC) may express mimic reactions of sufferance, such as crying, shouting, and screaming, due to mobilization or from other sources of possible pain, such as visceral pain
Summary
In the practice of medicine, pain is often encountered consequential to disease and/or acquired brain injuries. As noted by Schnakers and Zasler [18], these factors have driven greater levels of introspection regarding the clinical assessment and treatment of persons with DoC in general, and regarding issues of pain assessment and management. These advances in DoC knowledge and practice have brought to light medicolegal as well as ethical considerations in the context of ongoing controversies regarding pain and suffering in persons with DoC, leading to a multitude of clinical management challenges extending well beyond the boundaries of end–of–life decisions [24,25,26].
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