Advances in our understanding of coma and the resulting altered states of consciousness raise new ethical questions that were discussed at the annual meeting of the International Neuroethics Society which took place a few months ago at the Research Institute Montreal clinics (IRCM).
Over the past 15 years, researchers have succeeded in showing signs of consciousness in individuals supposedly in a vegetative state, thus revealing various problems. Are these people in pain? Do they have a sufficient quality of life to justify continuing treatment? Would they agree to continue living in this state if they could express themselves?
These delicate questions were discussed by neuroethics experts from around the world who met at the IRCM last fall.
“Thanks to brain imaging technologies, we have been able to detect brain activity in response to external stimuli which testifies to a certain consciousness which was however undetectable by traditional clinical examinations in patients who were believed to be in a state of irreversible unconsciousness. If we detect a small conscience, we can therefore imagine that the person is suffering, that she may be feeling pain, and this is perhaps even more cruel and difficult as a human situation. [que ce que l’on pensait] », explained in an interview the director of the pragmatic health ethics research unit at the IRCM, Éric Racine, who organized this annual meeting of the International Neuroethics Society.
The neurologist Steven Laureys, who was one of the first to highlight signs of consciousness in patients who had been clinically declared in a vegetative state, that is to say in an unconscious awakening, rightly confirmed in a published article In Tea Lancet Neurology that the application of painful stimuli to people in a state of minimal consciousness activated the various cerebral structures making up the pain network, as in healthy subjects.
“This tells us that most likely they are in pain and that they need to be given analgesic treatments to make them comfortable,” concludes the researcher from the GIGA Consciousness Unit, University of Liège, as well as the Center of CERVO research, from Laval University.
Éric Racine relates that “at the beginning, the argument was that the more the person is conscious, the more we must keep him alive. Then, we realized that there could be pain perception and that it was an aggravating problem. Just because there is more awareness doesn’t necessarily mean that life is more worth living in a state like that, because unfortunately treatments haven’t evolved that fast.”
For some, more awareness equals more justification for aggressive care. For others, more awareness equals more pain perception, and therefore more palliative care. There is also another approach which is to make sure to respect the wishes of the person, who would like either that we do everything to keep him alive if he finds himself in this state, or that we stop treatments. These different points of view were therefore discussed during the meeting.
For example, the professor of neurology at the Weill Institute for Neurosciences at the University of California, San Francisco, Dr.r Claude Hemphill, who is in favor of keeping alive and offering all possible care to these people whose consciousness is greatly altered, recalled that at the beginning, the defenders of this approach had to face and fight a sort of therapeutic nihilism, defeatism, asserting that there was nothing to be done for any of these patients.
“Today, there is enough data to say that these people can have pain, as they can have pleasure. They can still have a quality of life. Seen from the outside, we tend, we healthy people, to underestimate this capacity, “says the Dr Laureys who did not participate in the meeting.
“There are some patients who will recover and we really need to increase our efforts to give them access to rehabilitation techniques and new therapeutic interventions, such as transcranial electrical stimulation”, pleads the Dr Laureys, who has successfully experimented with this latter technique. “There are other patients we have to decide to let go. The citizen must help us and make an advance declaration because it can happen to each of us, at any time. »
Long term prognosis
The Dr Alexis Turgeon, a specialist in intensive care at the CHU de Québec-Université Laval, is leading a research program that aims to improve the way of determining the long-term prognosis of patients who are in an altered state of consciousness following a serious craniocerebral trauma in order to provide “the most objective information possible to the relatives” of the patients.
“A person who arrives in critical condition in an intensive care unit is most often unable to give consent to care. However, since we must always ensure that our interventions respond to the person’s wishes, it is the loved ones who become our respondents and with whom we must communicate to obtain this consent.
Relatives therefore need to know if the person will survive, but above all in what state they will survive, if the quality of life they will have would be acceptable for them,” explains Dr.r Turgeon, who holds the Canada Research Chair in Neurological Intensive Care and Traumatology.
The researcher has developed a protocol using a combination of clinical examinations, serological tests measuring in particular certain cerebral cell debris, various types of medical imaging (magnetic resonance, computed tomography, electrophysiology) which should improve the ability to formulate a more objective and more precise long-term prognosis “to help families to progress and to know if the interventions which are made taking into account the prognosis which one believes to be the best are always acceptable or not”. This protocol is tested in several hospitals in Canada, France, England and Brazil.
At these same sites, the Dr Turgeon is also coordinating a clinical trial, called the HEMOTION study, to see if blood transfusions with higher levels of hemoglobin — which carries oxygen — than are normally used for another critically ill patient population may increase oxygenation to trauma-damaged areas and improve long-term patient prognosis.
“The care that is given to the patient during the acute phase aims to prevent secondary brain damage, that is to say that other brain cells die. As the brain is extremely vulnerable to lack of oxygen, optimizing oxygen transport especially in areas that have been a little less traumatized and where there are still living cells could minimize the secondary brain damage that could occur”, explains he.
The patients were randomly allocated to the usual transfusion group or to the higher transfusion group and it was assessed whether, in the long term [après six mois]this intervention improved the prognosis.