Biological Psychology

Disorders of Consciousness

Dr Astrid Schepman
School of Psychology, University of Chester
Content warning – details and footage of patients suffering from the
aftermath of severe head injuries, some details of causes of brain injuries,
discussion of death
Additional info behind the images
slide colours
Slide yellow: Info
 Right click on the images and choose dissemination, feel free to
Edit Alt Text to see more details – see ask questions, always
think 
below for an example
Slide green: Just a section
header to provide
structure

Slide blue: Chance for you

to discuss with neighbour,
share with class, or just
reflect (no pressure to
talk)
Disorders of consciousness – session aims
 Gain understanding of disorders of consciousness and their
causes; Awareness of benefits and limitations of recent research
and new technologies in improving patients’ and relatives’ lives

 Legal and ethical context

Video of TJ in vegetative state
 TJ was 15 and healthy. During PE class, he had sudden cardiac
arrest.
 After spending over 12 minutes without receiving CPR or
defibrillation, TJ suffered severe brain damage and ended up in a
persistent vegetative state
https://www.youtube.com/embed/2kpPHfs6z7U?start=90
 Until 3:14 “and yet there he is”
Helping prevent brain damage following
cardiac arrests: CPR / defibrillator
 https://www.youtube.com/embed/8A0kljQU48U

 .

 https://www.nhs.uk/conditions/first-aid/cpr/ (best with rescue

breaths to oxygenate the blood)
DISORDERS OF CONSCIOUSNESS:
DEFINITIONS AND DIAGNOSIS
Normal consciousness
 Awake: state of physiological arousal
 Eyes open, often motor output, different from sleep,
stupor etc.
 Aware: able to process information from the environment,
own thoughts, have experiences
 Both needed for a normal state of consciousness
Disorders of consciousness
 Coma
 Persistent vegetative state
(renamed Unresponsive
Wakefulness Syndrome by
some for dignity reasons)
 Minimally Conscious State
Complex diagnostic process
 Clinical observation – no specific lab test
 Exclude other conditions and treat potential contributors
 Assess brain damage (CT, MRI)
 Pathway check – sensory / motor (neurophysiologist)
 Use of diagnostic scales
 See Alt text (right click that image for more info ->)
Vegetative state diagnostic criteria
 Present:
 Spontaneous respiration and circulation
 Cycle of eye opening and closing, seeming sleep-wake cycles
 Deficiencies:
 No awareness of self, environment, no ability to interact with
others
 No sustained or purposeful voluntary behaviours, either
spontaneously or as response to stimuli
 No language, comprehension, meaningful expression
Minimally conscious state
 In summary: relatively low-level responses indicative of minimal
consciousness, e.g. non-reflexive response, purposeful
behaviours
 See Alt text (right click that image for more info ->)

 Recent subcategorization: MCS+ and MCS –

 + Higher level cognitions (language),
 - lower level (e.g. sensory, visual tracking)
Version of
Wessex Head
Injury Matrix

Most Advanced
Behaviour
(MAB)
provides score
Diagnosis is hard; diagnoses can change;
some claim much misdiagnosis – but:
CAUSES OF DISORDERS OF
CONSCIOUSNESS: BRAIN DAMAGE
Oxygen
deprivation
Infections (e.g. meningitis, vasculitis, encephalitis)
Toxins
End-stage neurodegeneration
Metabolic
Traumatic Brain Injury (TBI): Deceleration; Diffuse axonal
injury: Extensive damage to white matter tracts
Aneurysm
Stroke
PROGNOSIS FOR DISORDERS OF
CONSCIOUSNESS
Prognosis: pathways
Prognosis: Possible outcomes
Prognosis: timescales
 VS / UWS: If no signs of recovery by this time, poor prognosis:
 Non-traumatic (3 months)
 Traumatic (usually 12 months)
 MCS: Some longer recovery periods observed
 Of those who emerge: 60% did so in 2 years; 30% in 2-4 years; longer
rare, but also observed; disability.

 Long term monitoring and assessment needed.

CASE STUDIES: VEGETATIVE STATE
Tony Bland (UK)

 Hillsborough disaster (1989)

 Anoxia: brain injuries following rib / lung injuries (age 18)
 PVS: Brain stem intact; cortex not active
 Long legal (test) case on withdrawal of life support
 Died age 22
Tony Bland legal ruling
 [Persistent Vegetative State] …”arises from the destruction, through
prolonged deprivation of oxygen, of the cerebral cortex, which has resolved
into a watery mass. The cortex is that part of the brain which is the seat of
cognitive function and sensory capacity. Anthony Bland cannot see, hear or
feel anything. He cannot communicate in any way. The consciousness which
is the essential feature of individual personality has departed for ever. On the
other hand the brain stem, which controls the reflexive functions of the body,
in particular heartbeat, breathing and digestion, continues to operate. In the
eyes of the medical world and of the law a person is not clinically dead so
long as the brain stem retains its function.”
 https://www.swarb.co.uk/c/hl/1993airedale_bland.html
 Terri Schiavo (US)
 Cardiac / respiratory arrest (1990)
 Difficulty resuscitating
Terri Schiavo (US) – Patient Outcome
 CT scan widespread neuronal
loss
 Hydrocephalus ex vacuo
 Thalamic implant, but did not
help
 Died 2005 after prolonged
legal / political wrangle
Terri Schiavo: death
and autopsy
 Autopsy report:
Complications of Anoxic-
ischemic encephalopathy
 http://www.abstractappeal.c
om/schiavo/autopsyreport.p
df

 Low brain weight, larger

ventricles, abnormal cells
Medical Examiner on Terri Schiavo:
CASE STUDIES: MINIMALLY CONSCIOUS
STATE AND (RARE) RECOVERY
Sarah Scantlin (US)
 Hit by car age 18: Coma
 Surgery: excise blood clot, LH, frontal
 Further damage but saved life
 MCS; blinks / grunts
 Age 37: Regained speech, media attention
 Plasticity, recovery of function
 Died, reportedly of respiratory issues and failing
blood pressure aged 50
 Terry Wallis (US)
 Truck crash age 19
 MCS
 Age 38: speech / conscious awareness
 Plasticity: novel wiring, unusual brain
structures; possible axon regrowth
 Anterograde amnesia
CURRENT RESEARCH:
BENEFITS AND LIMITATIONS
BASIC BRAIN ACTIVITY
Brain activity levels in a healthy control, a person who is brain dead, and a person in a
vegative state (50% activity compared to normal, but not brain dead) – see Alt text for
more detail.
 Laureys, S. (2005). Death, unconsciousness and the brain. Nature Reviews Neuroscience,
6(11), 899-909. https://doi.org/10.1038/nrn1789
 http://espra.scicog.fr/death_unconsciousness_NatureRevNeurosci05.pdf
Cortical activity in response to painful stimuli in healthy controls and in patients with brain death
or in a vegetative state.
a: Pain matrix activates
b: No activation
c: Lower level activation; higher level pain centres not activated.
From same paper as previous slide – see alt text for details
 Auditory response to clicks (possible hearing, but
comprehension not certain)
Controls PVS

MCS

Controls and MCS activated temporal Brodmann areas 41, 42 (Primary auditory
cortex), and 22 (association cortex).

PVS activated areas 41 and 42, but not 22.

This and connectivity patterns suggest B may be able to hear, but C unlikely to.
COMMUNICATION VIA SCANNING: A
SCUFFLE IN THE COMA WARD
 Diagnosis: PVS and intentional responding:
Owen et al. 2005 / 2006
 23 year old woman, severe
traumatic brain injury traffic
accident
 Five months after accident: PVS
diagnosis
From Owen et al. 2005
 fMRI: response to spoken sentences
minus noise
 Observe: brain response like healthy
controls
 bilaterally in the middle and
superior temporal gyri
 Like controls also left frontal region
when sentences were ambiguous.
 Could be “implicit”, and patient may
not be aware
A new task: image playing tennis, or
moving around your house
Patient same activity as controls:
Intentionality; volitional control over thoughts.
Owen et al. (2006): Interpretation and
critique
 PVS diagnosis, but communication / cooperation / intentional
behaviour in brain patterns
 Consciously aware of surroundings
 BUT: Debate (2007): might words trigger activation without
conscious awareness?

 Right click image for more details + link ->

 An additional control condition
 Response (2007): new control: words
only, but no instruction to imagine
 No brain activation in relevant areas in
patient or control
 Bolster interpretation that there was
volitional control
 Communiation via thoughts in
PVS: Monti et al. (2010)
 Communicate via brain activity
patterns
 Questions written by family
 Answers not known to researchers
 Answered correctly via thoughts
 Major breakthrough, news world-
wide; NEJM, Feb 2010
Panorama video segment
 http://www.bbc.co.uk/news/health-202680
44
 Video featuring Adrian Owen scanning a
patient using the tennis / navigation
method.
 PVS-diagnosed patient able to indicate
he is not in pain.
Reaction to Panorama:
“A scuffle in the coma ward”
 British Medical Journal reaction: Balanced view;
patient may not be vegetative; fMRI not yet useful in
practice; only few patients have shown capacity
 Panorama & Owen team reaction in BMJ: diagnosis
made by neurologist, should not be made by TV
viewing doctors
 Right-click image for more background reading ->
PROMISING AVENUES FOR TREATMENT?
Pharmacotherapy
 Drugs might help, particularly those that aid neurotransmission
 Trials of drugs with actions on:
 Gamma amino-butyric acid (GABA), e.g. zolpidem and baclofen
 Dopaminergic agents, e.g. levodopa, also used in Parkinson’s disease; see also book /
film “Awakenings” (based on book by Oliver Sacks)
 Some antidepressants
 Overall: Some transient improvements, some more lasting, some
trials no effect
 Right-click image for more information ->:
Neuromodulation

Deep Brain Stimulation (DBS) promising, but large controlled

clinical trials yet to be run.

Transcranial Direct Current Stimulation (tDCS) encouraging results

in acute and chronic patients.
Vagus nerve stimulation

Patient VS 15 years post traumatic brain injury; implant; EEG changed;

Scores on the Coma Recovery Scale-Revised (CRS-R) test improved, VS
-> MCS.
BUT: patient died after; not reported in paper!!!
Researchers say cause of death was unrelated pulmonary
complications.
LEGAL, MORAL, AND ETHICAL ISSUES
Clinically Assisted Nutrition and Hydration
(CANH)
 CANH is medical treatment to provide nutrition and fluids to very
ill patients who can't eat or drink.
 Tube feeding. This might be a tube inserted through a patient's
nose (a nasogastric tube), a tube going directly into the person's
stomach (a 'PEG' or 'RIG') or an infusion into a vein.
 CANH is not food or drink or nutritional supplements given by
mouth. (GMC website)
Supreme Court ruling July 2018
 Decisions about CANH do not need court approval any longer
 If thorough decision-making process has been followed and there is
agreement between the patient's family and carers and the healthcare
team that it's not in the patient's best interests to continue with CANH.
Follow Mental Capacity Act 2005 – see links below
 No agreement: still go to court
GOING TO COURT
The Court of Protection
 Makes decisions on financial or welfare matters for people who
cannot make decisions at the time they need to be made (they
‘lack mental capacity’).
 The case of GU
https://www.bailii.org/ew/cases/EWCOP/2021/59.html
GU’s accident
 GU former distinguished airline pilot, aged 63, enjoying retirement
in Thailand with wife.
 Mid-April 2014: Cleaning pond, examined pump.
 Forgot to switch off electricity; electrocution accident, possibly
complicated by drowning.
 Cardiorespiratory arrest; Significant delay before cardiopulmonary
resuscitation was started.
GU after the accident
 Local hospital - CT brain scan - no other intracranial lesion.
 Ventilator until mid-May 2014, then gradually weaned off ventilator.
 Transfer to Royal Hospital for Neuro-disability (RHND), London,
September 2014.
 GU unconscious, no behavioural signs indicating any awareness
either of himself or his environment this whole period.

 Diagnosis: Initially coma, then vegetative state, then persistent

vegetative state
GU at the RHND
 GU medically stable for years. Consistently observed
and monitored by a highly specialist team of nurses
and therapists. Wonderful care.
 No evidence of awareness. All responses were either
automatic or reflexive. No perceptible change over
time.
Main persons / organisations involved in
court case
 The Hospital (RHND)
 GU’s brother E
 GU’s son A
 GU (lacking mental capacity)
represented by the Official
Solicitor, here Debra Powell, QC
 Who do you think should have
the greatest say in what
happens to GU next?
 THE COURT OF PROTECTION
 Before:
 THE HONOURABLE MR JUSTICE HAYDEN,
VICE PRESIDENT OF THE COURT OF
PROTECTION
 Between:
 NORTH WEST LONDON CLINICAL
COMMISSIONING GROUP (applicant) and –
GU (By his Litigation Friend, the Official Solicitor)
 Hearing date: 15th July 2021
Clinically-Assisted Nutrition and Hydration:
CANH and the will of the patient
 Decisions about CANH: Focus on right decision for individual.
 Strong presumption: Patient’s best interests to receive life-
sustaining treatment.
 But: Presumption can be rebutted if clear evidence that patient
would not want CANH provided in the circumstances.
 Crucial to carry out proper best interests assessments.
 https://www.bma.org.uk/advice-and-support/ethics/adults-who-lack-capacity/clinically-assisted-nutrition-
and-hydration/deciding-best-interests
Discuss or reflect
 As a neutral observer, what seems to be in the best interest of the
patient?

 Continue life-sustaining support

 Discontinue life-sustaining support with the consequence that the
patient dies (palliation for process of dying so no suffering)
Best interest request by E, disagreement,
judge reaction
 August 2018 GU's brother E asked for Best Interest decision on
CANH following law change
 Hospital: “The rest of the family does not agree with this new decision
and therefore [GU] will continue to be cared by nursing staff.”
 Only GU's son (A) wants to keep CANH
 Judge: “..the apparent assumption that in the face of family
disagreement ’therefore [GU] will continue to be cared for by nursing
staff’ is a troubling non sequitur.” “Family dissent to a medical
consensus should never stand in the way of an incapacitated
patient's best interests being properly identified.”
Voice of vulnerable individual at the centre
 There is a risk of silencing the voice of the vulnerable individual at
the centre of the process.
 Autonomy does not evaporate with loss of capacity. It may
become harder to establish what the person wanted, but it’s
essential.
 GU's treating clinicians (by August 2018): GU in a prolonged
disorder of consciousness; no change; no prospect of future change.
 Treatment was both futile and potentially burdensome.
Take some time to think about this
 If treatment has become futile and possibly burdensome, is it
ethical to continue with it?
 Expert Professor Derick Wade - Professor of
Neurorehabiliation– reviewed case
 “…[GU] has been unaware of himself or his environment from the
outset, and … there is no prospect of any recovery. He may live in
this state for up to 10 years. ….. his past wishes would have been
that he should not continue with life-sustaining medical treatment.”
 …GU unlikely to be having any experiences, but that if he was,
they would generally be unpleasant.
 The primary diagnosis is severe hypoxic brain damage. There is
no alternative treatable diagnosis. There is no secondary
subsequently developing complication that obscures the nature
and extent of the brain damage.
Multiple reviews of GU’s condition
 Spring 2019 Review period. 5 x Wessex Head Injury Matrix,
usually 4. (once a little higher, but may be reflexive)
 Autumn 2020 Review period. 4 x Wessex Head Injury Matrix,
highest score 4.
 Score of 4: Vegetative state
 Arousal levels "low“, reflexive, non-meaningful responses to
sensory stimuli in keeping with low-level Prolonged Disorder of
Consciousness.
Discuss or reflect
 Are you persuaded that GU was not going to get better?
Witnesses to GU’s previously expressed
wishes (1)
 E: "I do not believe he would want ongoing life-sustaining
interventions in his situation. When my mother had Alzheimer's,
towards the end, he expressed very strong views. He said
things like: ‘for God's sake, if ever I get like this, take me out
and shoot me’ ”
 RB (sister): “He said things like ‘if I do not have my mental
facilities there is no reason for me to be here’ ”
 NU (first wife): “He would want all life-sustaining treatment to
stop. his greatest fear would to be in a vegetative state. He
would make me promise to "pull the switch" so as to end his
life rather than be a vegetable. It was a fear of his.”
Witnesses to GU’s previously expressed wishes (2)
 PU (third wife): “as long as all the family agree I think it is what
[GU] would want us to do. You have my support and anything I
can do to help make it easier for you please let me know. I now
realize after four years that [GU] will not be coming back and it's
not good for him to stay like this for much more time.”
 Captain H (close friend): “We both agreed that prolonged suffering
to the individual and their families was redundant and
unnecessary… he would not want this for himself languishing
through clinically assisted nutrition in my opinion.”
Son A: Objection to deprivation of Nutrition and
Hydration
 "My view on the removal of my father's feeding and hydration
tube has not changed since it was first raised in August 2018. I
did not agree then and will not agree now to such a decision.
There is nothing that will change my mind on this…“
 Universal declaration of Human Rights - "everyone has the
right to adequate food, housing and medical care. To deprive
my father from this right is unbearable to accept.”
 “Maybe he did say to some people 'If I'm ever like that shoot
me' but ok shoot him, don't starve him."
Discuss or reflect
 Should A’s views determine the outcome?
 Should GU’s views (relayed by witnesses) determine the
outcome?
Judge’s response to contradictory views
 Only dissenting voice, son, has a moral objection to the
withdrawal of food and fluid from his father. He is not disputing
any of the factual evidence.
 I have concluded that it is not in the best interests of [GU] to
continue with clinically assisted nutrition and hydration.
 I am satisfied that the local team has the necessary expertise
to provide all appropriate palliative end-of-life care.
The hospital criticised (1)
 Judge criticised the hospital for not carrying out best interest review
sooner
 Human rights: Dignity, autonomy, respect of patient’s own wishes
 GU has been unaware of himself or the outside world for 7 years. No
decision was taken as to his "best interests". His voice remained
unheard for what many in this case regard as an unconscionable
period.
 Respecting human dignity in these circumstances can prove to be
challenging. The striking facts of this case require me to confront
whether GU's dignity has been avoidably compromised and, more
generally, how dignity may be evaluated.
The hospital criticised (2)
 Official Solicitor: Hospital showed "a complete abrogation of
responsibility to consider properly or at all, and to determine whether
it was in GU's best interests and therefore lawful to continue to give
him an invasive medical treatment, CANH.“
 Hospital: "RHND charity was set up with the aim of giving "permanent
relief to such persons as are hopelessly disqualified for the duties of
life by disease, accident or deformity," (originally called the Hospital
for Incurables). RHND has always taken seriously its approach to
ensuring a strong ethical position on the end of life care
 Judge: Needs to comply with current legislation
Important learning outcomes and
generalisation
 Ethical decision making in real life
 Court of Protection has wider roles, interesting to follow (e.g.
mental health capacity issues, forensic settings)
END OF LECTURE