Prolonged disorders of consciousness: A response to a “critical evaluation of the new UK guidelines.”

Abstract

Background In 2020, The London Royal College of Physicians published “Prolonged disorders of consciousness following sudden-onset brain injury: national clinical guidelines”. In 2021, in the journal Brain, Scolding et al. published “a critical evaluation of the new UK guidelines”. This evaluation focussed on one of the 73 recommendations in the National Clinical Guidelines. They also alleged that the guidelines were unethical. Criticisms They criticised our recommendation not to use activation protocols using fMRI, electroencephalography, or Positron Emission Tomography. They claim these tests can (a) detect ‘covert consciousness’, (b) add predictive value and (c) should be part of routine clinical care. They also suggest that our guideline was driven by cost considerations, leading to clinicians deciding to withdraw treatment at 72 h. Evidence Our detailed review of the evidence confirms the American Academy of Neurology Practise Guideline (2018) and the European Academy of Neurology Guideline (2020), which agree that insufficient evidence supports their approach. Ethics The ethical objections are based on unwarranted assumptions. Our guideline does not make any recommendations about management until at least four weeks have passed. We explicitly recommend that expert assessors undertake ongoing surveillance and monitoring; we do not suggest that patients be abandoned. Our recommendation will increase the cost We had ethicists in the working party. Conclusion We conclude the “critical evaluation” fails to provide evidence for their criticism and that the ethical objections arise from incorrect assumptions and unsupported interpretations of evidence and our guideline. The 2020 UK national guidelines remain valid.