Minimal Consciousness Research Articles

Can Eye Tracking Help Assess the State of Consciousness in Non-Verbal Brain Injury Patients?

Background/Objectives: Developments in eye-tracking technology are opening up new possibilities for diagnosing patients in a state of minimal consciousness because they can provide information on visual behavior, and the movements of the eyeballs are correlated with the patients' level of consciousness. The purpose of this study was to provide validation of a tool, based on eye tracking by comparing the results obtained with the assessment obtained using the Coma Recovery Scale-Revised (CRS-R). Methods: The mul-ti-center clinical trial was conducted in Poland in 2022-2023. The results of 46 patients who were not able to communicate verbally due to severe brain injury were analyzed in this study. The state of consciousness of patients was assessed using the Minimally Conscious State Detection test (MCSD), installed on an eye tracker and compared to CRS-R. The examinations consisted of performing the MCSD test on patients five times (T1-T5) within 14 days. Collected data were processed based on the FDA and GCP's regulatory requirements. Depending on the nature of the data, the mean and standard deviation, median and lower and upper quartiles, and maximum and minimum values were calculated. Passing-Bablok regression analysis was used to assess the measurement equiva-lence of the methods used. Results: There was no difference between the MCSD and CRS-R in the raw change between T5 and T1 time points, as well as in the total % of points from all time points. The MCSD results from each time point show that at least the first two measurements serve to famil-iarize and adapt the patient to the measurement process, and the third and next measurement should be considered reliable. Conclusions: The results indicated a significant relationship be-tween the scores obtained with MCSD and CRS-R. The results suggest that it seems reasonable to introduce an assessment of the patient's state of consciousness based on eye-tracking technology. The use of modern technology to assess a patient's state of consciousness opens up the opportunity for greater objectivity, as well as a reduction in the workload of qualified personnel.

Mismatch Negativity and P300 in the Diagnosis and Prognostic Assessment of Coma and Other Disorders of Consciousness.

The objective of this study was to investigate the value of mismatch negativity (MMN) and P300 event-related potentials for discriminating the consciousness state and predicting improvement of consciousness at 6months in patients with coma and other disorders of consciousness (DOC). We performed MMN and P300 on 42 patients with DOC with a mean onset time of 40.21 ± 19.43days. These patients with DOC were categorized into coma, unresponsive wakefulness syndrome (UWS), minimal consciousness minus (MCS-), and minimal consciousness plus (MCS +) groups according to neurobehavioral assessment and the Coma Recovery Scale-Revised score. The primary outcome was the improvement of consciousness at 6months in patients with DOC. We assessed the efficacy of MMN and P300 in quantitatively predicting the prognosis at 6months and the capability of MMN and P300 parameters to differentiate between DOC. At least one significant difference in either MMN or P300 parameters was displayed among the DOC groups, but not between the MCS- and MCS+ groups (significance level: 0.05). Both MMN and P300 amplitudes showed desirable predictive accuracy at 6months, with areas under the curve (AUCs) of 0.859 and 0.856, respectively. The optimal thresholds for MMN and P300 amplitudes were 2.044 and 1.095μV. However, the combined MMN-P300 amplitude showed better 6-month predictive accuracy (AUC 0.934, 95% confidence interval 0.860-1.000), with a sensitivity of 85% and a specificity of 90.9%. MMN and P300 may help discriminate among coma, UWS, and MCS, but not between patients with MCS- and patients with MCS+ . The MMN amplitude, P300 amplitude, and especially combined MMN-P300 amplitude at 6months may be interesting predictors of consciousness improvement at 6months in patients with DOC. Chinese Clinical Trial Registry identifier ChiCTR2400083798.

Consciousness in non-REM-parasomnia episodes.

Sleepwalking and related parasomnias are thought to result from incomplete awakenings out of non-rapid eye movement (non-REM) sleep. Non-REM parasomnia behaviours have been described as unconscious and automatic, or related to vivid, dream-like conscious experiences. Similarly, some observations have suggested that patients are unresponsive during episodes, while others that they can interact with their surroundings. To better grasp and characterise the full spectrum of consciousness and environmental (dis)connection associated with behavioural episodes, 35 adult patients with non-REM sleep parasomnias were interviewed in-depth about their experiences. The level of consciousness during parasomnia episodes was reported to be variable both within and between individuals, ranging from minimal or absent consciousness and largely automatic behaviours (frequently/always present in 36% of patients) to preserved conscious experiences characterised by delusional thinking to varying degrees of specificity (65%), often about impending danger, variably formed, uni- or multisensory hallucinations (53%), impaired insight (77%), negative emotions (75%), and variable, but often pronounced, amnesia (30%). Patients described their experiences as a dream scene during which they felt awake ("awake dreaming"). The surroundings were either realistically perceived, misinterpreted (in the form of perceptual illusions or misidentifications of people), or entirely hallucinated as a function of the prevailing delusion. These observations suggest that the level of consciousness, amnesiaand sensory disconnection during non-REM parasomnia episodes is variable and graded. In their full-fledged expression, non-REM parasomnia experiences feature several core features of dreams. They therefore represent a valuable model for the study of consciousness, sleep-related sensory disconnection and dreaming.

Neuropsychological interpretation of disorders of consciousness using data from instrumental (neurophysiological) methods for diagnosing brain activity

The relevance of the problem under consideration is determined by the need to develop and improve interdisciplinary approaches to the diagnosis and rehabilitation of disorders of consciousness in patients with brain pathology. The purpose of the article is an analytical review of the methods of neuropsychological and neurophysiological diagnostics and rehabilitation work with patients in reduced states of consciousness. It is noted that the neuropsychological content of the concept of "consciousness" is insufficiently developed and there is no unified point of view on the brain basis of consciousness, as well as on methodological and procedural limitations that arise when a neuropsychologist works with patients in a vegetative state of consciousness and in a state of minimal consciousness. The problem of consistency of the results of behavioral (neuropsychological) and instrumental (neurophysiological) methods for assessing the level of states of consciousness conducted by different specialists (neuropsychologists, neurologists, neurophysiologists) who are part of a multidisciplinary team is considered. The possibility of combining the procedure of neuropsychological examination and instrumental (neurophysiological) methods in the diagnosis of patients in a vegetative state of consciousness, in a state of minimal consciousness) and the prognosis of restoring the level of consciousness is analyzed. The possibility of an integrated approach to the diagnosis of a state of consciousness associated with a combination of behavioral (observation-based) and objective (instrumental) research methods is confirmed, and possible ways of its implementation are considered.

“The Union of the Soul and the Body”: Merleau-Ponty on Being in the World

AbstractMerleau-Ponty’s theory of the body is often depicted as emphasizing the distinction between the physical and the conscious dimension of the body. This distinction, however, runs the risk of recreating the tension between the physical and the conscious that is at the center of the mind-body problem. In view of this, I argue for a different interpretation of Merleau-Ponty, according to which his theory of the body is an attempt to establish “the union of the soul and the body” (Merleau-Ponty, 2012: 91, 99) by way of an analysis of the phenomenon of being in the world. This phenomenon does not just go beyond reflective but also beyond pre-reflective consciousness. It is an essential feature of living beings that has a teleological structure and that stands in the way of a reduction of living beings to physical objects. In the end, Merleau-Ponty argues for an antireductionist and metaphysically quite charged concept of life that is supposed to bridge the gap between the conscious and the organic dimension of human existence and that holds important insights for the contemporary debates on minimal consciousness, the life-mind continuity, autopoietic enactivism, and causation.

Diagnostic criteria for prolonged and chronic disturbances of consciousness after aneurysmal subarachnoid hemorrhages

In recent years, prolonged states of impaired consciousness became widespread among patients with aneurysmal subarachnoid hemorrhage. Treatment and maintenance of vital functions in such patients represent a complex medical, economic and social problem. In this regard, searching for the causes of prolonged states of impaired consciousness and predicting the outcomes are important. To analyze available literature data on prevention and treatment of prolonged states of impaired consciousness after aneurysmal subarachnoid hemorrhage. We reviewed the PubMed database using the keywords «unresponsive wakefulness syndrome», «persistent vegetative state2, «minimal consciousness state» and «outcome of subarachnoid hemorrhage». Only 4 reports devoted to the causes and treatment outcomes in patients with prolonged impairment of consciousness after aneurysmal subarachnoid hemorrhage were found. At the same time, patients with aneurysmal subarachnoid hemorrhage comprise up to 11% among all cases of prolonged states of impaired consciousness. Examination, management and treatment of patients with prolonged impairment of consciousness after aneurysmal subarachnoid hemorrhage are carried out according to general principles without taking into account specific etiological and pathogenetic factors. Increased number of patients with prolonged impairment of consciousness after aneurysmal subarachnoid hemorrhage necessitates analysis of etiopathogenesis and outcomes of these disorders based on modern clinical, instrumental and laboratory assessment of the brain.

Neurophysiological and Psychometric Outcomes in Minimal Consciousness State after Advanced Audio-Video Emotional Stimulation: A Retrospective Study.

In the last ten years, technological innovations have led to the development of new, advanced sensory stimulation (SS) tools, such as PC-based rehabilitative programs or virtual reality training. These are meant to stimulate residual cognitive abilities and, at the same time, assess cognition and awareness, also in patients with a minimally conscious state (MCS). Our purpose was to evaluate the clinical and neurophysiological effects of multi-sensory and emotional stimulation provided by Neurowave in patients with MCS, as compared to a conventional SS treatment. The psychological status of their caregivers was also monitored. In this retrospective study, we have included forty-two MCS patients and their caregivers. Each MCS subject was included in either the control group (CG), receiving a conventional SS, or the experimental group (EG), who was submitted to the experimental training with the Neurowave. They were assessed before (T0) and after the training (T1) through a specific clinical battery, including both motor and cognitive outcomes. Moreover, in the EG, we also monitored the brain electrophysiological activity (EEG and P300). In both study groups (EG and CG), the psychological caregiver's aspects, including anxiety levels, were measured using the Zung Self-Rating Anxiety Scale (SAS). The intra-group analysis (T0-T1) of the EG showed statistical significances in all patients' outcome measures, while in the CG, we found statistical significances in consciousness and awareness outcomes. The inter-group analysis between the EG and the CG showed no statistical differences, except for global communication skills. In conclusion, the multi-sensory stimulation approach through Neurowave was found to be an innovative rehabilitation treatment, also allowing the registration of brain activity during treatment.

Predictors of long-term decannulation in patients with disorders of consciousness.

The predictors of tracheostomy decannulation in patients with disorders of consciousness (DOC) are not comprehensively understood, making prognosis difficult. The primary objective of this study was to identify predictors of tracheostomy decannulation in patients with disorders of consciousness (DOC). The secondary aim was to evaluate the feasibility and safety of the modified Evans blue dye test (MEBDT) in tracheostomized DOC patients. This retrospective study included all patients with disorders of consciousness (DOC) who underwent tracheostomy and were admitted between January 2016 and September 2022. Age, sex, etiology, initial Glasgow coma scale (GCS), initial Coma Recovery Scale-Revised (CRS-R), diagnosis of unresponsive wakefulness syndrome (UWS) or minimal consciousness state (MCS), MEBDT, initial modified Rankin scale (mRS), and initial Functional Oral Intake Scale (FOIS) were collected upon study enrollment. The relationship between clinical characteristics and cannulation status was investigated through a Cox regression model. A total of 141 patients were included in the study. The average age of these patients was 52.5 ± 16.7 years, with 42 (29.8%) being women. During the study period, 86 subjects (61%) underwent successful decannulation. Univariate analysis revealed that decannulated patients exhibited a significantly better conscious state compared to those without decannulation (CRS-R: p < 0.001; GCS: p = 0.023; MCS vs. UWS: p < 0.001). Additionally, a negative modified Evans blue dye test (MEBDT) result was significantly associated with tracheostomy decannulation (p < 0.001). In the multivariate analysis, successful decannulation was associated with a higher level of consciousness (MCS vs. UWS, p < 0.001, HR = 6.694) and a negative MEBDT result (negative vs. positive, p = 0.006, HR = 1.873). The Kaplan-Meier analysis further demonstrated that MEBDT-negative patients and those in the MCS category had a higher probability of decannulation at 12 months (p < 0.001). The findings of this study indicate that a negative MEBDT result and a higher level of consciousness can serve as predictive factors for successful tracheostomy decannulation in DOC patients.

The Neurological Rehabilitation of Adults With Coma and Disorders of Consciousness.

Severe quantitative disorders of consciousness (DoC) due to acute brain injury affect up to 47% of patients upon admission to intensive care and early rehabilitation units. Nevertheless, the rehabilitation of this vulnerable group of patients has not yet been addressed in any German-language guidelines and has only been studied in a small number of randomized clinical trials. In an S3 clinical practice guideline project, a systematic literature search was carried out for interventions that could improve consciousness in patients with coma, unresponsive wakefulness syndrome, or minimally conscious state after acute brain injury, and an evidence-based evaluation of these interventions was performed. Recommendations concerning diagnostic methods and medical ethics were issued by consensus. Misdiagnoses are common in patients with DoC, with minimal consciousness often going unrecognized. Patients with DoC should, therefore, be repeatedly assessed with standardized instruments, particularly the Coma Recovery Scale-Revised. The literature search yielded 54 clinical trials, mostly of low quality; there were two randomized controlled clinical trials providing level 1 evidence. The best available evidence for the improvement of impaired consciousness is for the administration of amantadine (4 studies) and for anodal transcranial direct-current stimulation of the left dorsolateral prefrontal cortex in patients in the minimal conscious state (8 studies, 2 systematic reviews). Further important components of rehabilitation include positioning methods and sensory stimulation techniques such as music therapy. For the first time, evidence-based German-language clinical practice guidelines have now become available for the neurological rehabilitation of patients with DoC.

The evolutionary origins ofthe Global Neuronal Workspace invertebrates.

The Global Neuronal Workspace theory of consciousness offers an explicit functional architecture that relates consciousness to cognitive abilities such as perception, attention, memory, and evaluation. We show that the functional architecture of the Global Neuronal Workspace, which is based mainly on human studies, corresponds to the cognitive-affective architecture proposed by the Unlimited Associative Learning theory that describes minimal consciousness. However, we suggest that when applied to basal vertebrates, both models require important modifications to accommodate what has been learned about the evolution of the vertebrate brain. Most importantly, comparative studies suggest that in basal vertebrates, the Global Neuronal Workspace is instantiated by the event memory system found in the hippocampal homolog. This proposal has testable predictions and implications for understanding hippocampal and cortical functions, the evolutionary relations between memory and consciousness, and the evolution of unified perception.

Palliative care for people with long term neurological conditions: practices and reflections based on comprehensive care

The care for people with Long Term Neurological Conditions (LTNC) isn´t recognized as a major practice in Palliative Care (PC) scientific production; in daily basis, the assistance is focused on hygiene´s care and clinical observation. However, from the perspective of PC, the health professionals´ role is to promote the dignity of the human person. The concept of LTNC covers neurological diseases with a prognosis of long-time life with significant disabilities, end-of-life stage that is difficult to identify, with many symptoms and physical and cognitive impairments. In this paper, we considered the following situations: persistent vegetative state, minimal consciousness state and locked-in syndrome. This is a theoretical study of a qualitative nature, which aims to describe a new kind of PC practice with this population, based on first author PHD study. The concept of Comprehensive Care is the main theoretical framework for the paper. It is proposed a practice reconstruction based on the person´s biography occurs by several perspectives, especially through sensory stimuli related to prior patient´s occupational repertoire. Along with the detailed evaluation, the therapist does a careful and continuous monitoring, proposing activities, giving special attention to their reactions, being able to discriminate what pleases or not, and expanding the possibilities of encounter of people with LTNC and the environment which surround them. Therapist should also provide support and guidance to the family, which is in a vulnerable situation. Regardless of neurological reactions presented by the patients this practice helps reconstructing the meanings of the daily life of person with so severe disability. Sensory stimuli are shown as potential tools for a rehabilitation practice. Memory, history, identity, dignity, and subjectivity qualify the assistance for people with LTNC.

The Conscious Nematode: Exploring Hallmarks of Minimal Phenomenal Consciousness in Caenorhabditis Elegans.

While subcellular components of cognition and affectivity that involve the interaction between experience, environment, and physiology -such as learning, trauma, or emotion- are being identified, the physical mechanisms of phenomenal consciousness remain more elusive. We are interested in exploring whether ancient, simpler organisms such as nematodes have minimal consciousness. Is there something that feels like to be a worm? Or are worms blind machines? 'Simpler' models allow us to simultaneously extract data from multiple levels such as slow and fast neural dynamics, structural connectivity, molecular dynamics, behavior, decision making, etc., and thus, to test predictions of the current frameworks in dispute. In the present critical review, we summarize the current models of consciousness in order to reassess in light of the new evidence whether Caenorhabditis elegans, a nematode with a nervous system composed of 302 neurons, has minimal consciousness. We also suggest empirical paths to further advance consciousness research using C. elegans.

Efficacy of non-invasive brain stimulation for disorders of consciousness: a systematic review and meta-analysis.

The aim of this study is to evaluate the efficacy of non-invasive brain stimulation (NIBS) in patients with disorders of consciousness (DoC) and compare differences in efficacy between different stimulation modalities. We searched the PubMed, Cochrane Library, Web of Science, and EMBASE databases for all studies published in English from inception to April 2023. Literature screening and quality assessment were performed independently by two investigators. Weighted mean differences (WMDs) and 95% confidence intervals (CIs) were used to evaluate the therapeutic effects of NIBS. The Cochrane Q test and I2 statistic were used to evaluate heterogeneity between studies. Subgroup analysis was performed to identify the source of heterogeneity, and differences in efficacy between different stimulation modalities were compared by Bayesian analysis. A total of 17 studies with 377 DoC patients were included. NIBS significantly improved the state of consciousness in DoC patients when compared to sham stimulation (WMD: 0.81; 95% CI: 0.46, 1.17; I2 = 78.2%, p = 0.000). When divided into subgroups according to stimulation modalities, the heterogeneity of each subgroup was significantly lower than before (I2: 0.00-30.4%, p >0.05); different stimulation modalities may be the main source of such heterogeneity. Bayesian analysis, based on different stimulation modalities, indicated that a patient's state of consciousness improved most significantly after repetitive transcranial magnetic stimulation (rTMS) of the left dorsolateral prefrontal cortex (DLPFC). Diagnosis-based subgroup analysis showed that NIBS significantly improved the state of consciousness in patients with a minimal consciousness state (WMD: 1.11; 95% CI: 0.37, 1.86) but not in patients with unresponsive wakefulness syndrome or a vegetative state (WMD: 0.31; 95% CI: -0.09, 0.71). Subgroup analysis based on observation time showed that single treatment did not improve the state of consciousness in DoC patients (WMD: 0.28; 95% CI: -0.27, 0.82) while multiple treatments could (WMD: 1.05; 95% CI: 0.49, 1.61). Furthermore, NIBS had long-term effects on DoC patients (WMD: 0.79; 95% CI: 0.08-1.49). Available evidence suggests that the use of NIBS on patients with DoC is more effective than sham stimulation, and that rTMS of the left DLPFC may be the most prominent stimulation modality.

Multidimensional assessment of heartbeat-evoked responses in disorders of consciousness.

Because consciousness does not necessarily translate into overt behaviour, detecting residual consciousness in noncommunicating patients remains a challenge. Bedside diagnostic methods based on EEG are promising and cost-effective alternatives to detect residual consciousness. Recent evidence showed that the cortical activations triggered by each heartbeat, namely, heartbeat-evoked responses (HERs), can detect through machine learning the presence of minimal consciousness and distinguish between overt and covert minimal consciousness. In this study, we explore different markers to characterize HERs to investigate whether different dimensions of the neural responses to heartbeats provide complementary information that is not typically found under standard event-related potential analyses. We evaluated HERs and EEG average non-locked to heartbeats in six types of participants: healthy state, locked-in syndrome, minimally conscious state, vegetative state/unresponsive wakefulness syndrome, comatose and brain-dead patients. We computed a series of markers from HERs that can generally separate the unconscious from the conscious. Our findings indicate that HER variance and HER frontal segregation tend to be higher in the presence of consciousness. These indices, when combined with heart rate variability, have the potential to enhance the differentiation between different levels of awareness. We propose that a multidimensional evaluation of brain-heart interactions could be included in a battery of tests to characterize disorders of consciousness. Our results may motivate further exploration of markers in brain-heart communication for the detection of consciousness at the bedside. The development of diagnostic methods based on brain-heart interactions may be translated into more feasible methods for clinical practice.

A Case Report on Integrated Management of Hematological Abnormalities like Thrombocytosis and Leukocytosis in Sickle Cell Crisis Patient

Abstract: An Indian tribal population amongst dense forest area mainly suffers from sickle cell anaemia for a long. Considering the pathogenesis and geographical limitations only symptomatic management is available as there is no cure. Diagnosis of vaso-occlusive crisis or existing complication is a critical factor in sickle cell anaemia. Increased platelets, white blood cells, and clinical manifestations demand more attention in sickle cell patients. In the current case study, a patient was presented to the site for daycare management in minimal consciousness condition with SpO2 96% complains of left hip pain and unable to walk, joint pain, pallor, backache, and general weakness. The clinical evaluation thrombocytosis, leukocytosis, and x-ray suggested developed avascular necrosis of the hip. Considering his condition patient was started on an integrated treatment approach with T-AYU-HM Premium 300mg tablet. Regular monitoring of condition and strict adherence to treatment has lessened the financial and logistical burden of prolonged hospital stays, blood transfusion needs, and vaso-occlusive crisis sequelae. A key observation in this case study is a remarkable improvement in thrombocytosis, leukocytosis, and walking impairment in patient due to avascular necrosis. Looking at the improvement in the clinical conditions to proceed with utilising the information for better healthcare, a patient had consented for the same. The prognostic significance of platelet and white blood cells is suggestive of disease severity and progression in sickle cell anaemia patients. During the treatment, no untoward effect was reported or observed. This integrated treatment approach might become helpful in managing such kind of clinical complications in sickle cell anaemia. Keywords: Thrombocytosis, Leukocytosis, Vaso-occlusive crisis, Avascular necrosis, Sickle cell disease.

Muscular-tonic disorders in a vegetative and a minimal consciousness states

Muscular-tonic disorders (MTD) in prolonged disorders of consciousness (PDoC), including a vegetative state (VS) and a minimal consciousness state (MCS), are poorly understood.Aim. To systematize MTD in PDoC, to highlight the features of their dynamics depending on the change in consciousness.Material and methods. 87 patients in PDoC (VS — 52, MCS — 35) resulting from brain damage of diff erent etiology, lasting from 2 months up to 10 years. MTD, provoking hyperkinesis factors and consciousness were analyzed retrospectively in the dynamics and complex.Results. MTD had 98% of patients in PDoC. The ratio of occurrence of spasticity: hyperkinesis: postural spasms corresponded to 11:11:10, and hyperkinesis — dystonia: myoclonus/myokymia: athetosis: stereotypes: ballism: choreiform hyperkinesis: tremor — 17:10:6:3:2:1:1. Their clinical variants and features are noted. The total dynamics of MTD on improved consciousness was as follows. In general, regardless of the initial VS or MCS, their “change” (especially decrease) prevailed over “no changes” (p &lt; 0.001). Comparatively more often the decrease occurred in MCS “plus” (p &lt; 0.05); appearance/increase/modifi cation — in VS (p &lt; 0.05); “no changes” — in MCS “minus” (p &lt; 0.01). When considered separately, spasticity, dystonia, spasms, hemiballismus and stereotypy in MCS “plus” correlated (p &lt; 0.01) with the change of consciousness. The key provoking hyperkinesis factors in VS were pain and other sensory infl uences (p &lt; 0.01), but their role from MCS “minus” to MCS “plus” decreased, while the role both conscious emotions and movements increased (p &lt; 0.01).Conclusion. Along with academic interest, the data are promising in developing the prognosis, pathogenesis and treatment of PDoC.

The case of food botulism F

This case describes a rare case of food botulism F in a 42-year-old man, which developed after he ate dried fish. The disease proceeded in a severe form with the development of ophthalmoplegia, tetraparesis, and respiratory failure. Monovalent antitoxic serums against botulinum toxins A, B, and E were administered to the patient. However, on the third day of the disease, he developed fulminant toxic myocarditis with asystole. Despite successful resuscitation, the patient developed a post-resuscitation disease and anoxic encephalopathy. The disease was complicated by severe aspiration pneumonia caused by Klebsiella pneumoniae (ESBL+). The duration of mechanical ventilation was 12 days. His hemodynamics stabilized on the eighth day of illness, and on the 19th day of illness, physical activity and a state of minimal consciousness appeared. The patient was transferred to the rehabilitation department on the 22nd day of the illness.&#x0D; Doctors should be informed about the possibility of the development and severity of botulism caused by botulinum toxin type F. It is necessary to introduce polyvalent antibotulinic serum into clinical practice, including antitoxins against rare types of botulinum toxin.

Czy można uśmiercić pacjenta z powodu niskiej jakości życia? Uwagi na tle orzecznictwa Europejskiego Trybunału Praw Człowieka

The subject of the article is the issue of legal protection of the life of patients in a state of minimal consciousness, in a vegetative state or other form of serious health condition. The analyses the problem from the point of view of three high-profile court cases involving the termination of treatment of Vincent Lambert, Charlie Gard and Alfie Evans.

Antidepressant Use During Hospice Patients' Final Months on Routine Home Care.

Background: Antidepressants can be used to manage symptoms at the end of life, but the dying process can impact their use. Objectives: To examine the use of antidepressants during hospice patients' final months of home care. Methods: A retrospective case records review of 227 hospice patients in their last three months of care in a residential setting. Chart reviews were conducted of medication logs, hospice staff notes, and caregiver narratives to examine antidepressant use including types of medications prescribed and factors associated with medication maintenance. Results: Thirty percent of patients were prescribed at least 1 antidepressant for symptoms including depression, anxiety, pain, disturbances in sleep, and poor appetite. The majority (96.1%) of patients were not administered their antidepressant on the day of death, and more than half (61.8%) did not receive their antidepressant during their last 3days of life. A quarter (25.5%) of patients on antidepressants did not receive medication 4-7days prior to death while some (12.7%) went without their antidepressant for 8 or more days. Antidepressant use was discontinued by hospice staff or caregivers due to a variety of reasons including difficulty swallowing, minimal consciousness, confusion, nausea, or patient refusal. Conclusions: Antidepressants are prescribed to manage multiple symptoms at the end of life, but use is often disrupted during patients' final days. Tapering and other prescription adjustments may be warranted to avoid risk of antidepressant discontinuation syndrome (ADS).

Complexity and the Evolution of Consciousness

This article introduces and defends the “pathological complexity thesis” as a hypothesis about the evolutionary origins of minimal consciousness, or sentience, that connects the study of animal consciousness closely with work in behavioral ecology and evolutionary biology. I argue that consciousness is an adaptive solution to a design problem that led to the extinction of complex multicellular animal life following the Avalon explosion and that was subsequently solved during the Cambrian explosion. This is the economic trade-off problem of having to deal with a complex body with high degrees of freedom, what I call “pathological complexity.” By modeling the explosion of this computational complexity using the resources of state-based behavioral and life history theory we will be able to provide an evolutionary bottom-up framework to make sense of subjective experience and its function in nature by paying close attention to the ecological lifestyles of different animals.