Pain Perception in Disorders of Consciousness: Neuroscience, Clinical Care, and Ethics in Dialogue

详细信息    查看全文

• 作者：A. Demertzi (1) (2)
  E. Racine (3) (4) (5)
  M-A. Bruno (1) (2)
  D. Ledoux (1) (6)
  O. Gosseries (1) (2)
  A. Vanhaudenhuyse (1) (2)
  M. Thonnard (1) (2)
  A. Soddu (1) (2)
  G. Moonen (2) (7)
  S. Laureys (1) (2)
  
• 关键词：Pain ; End ; of ; life ; Vegetative state ; Minimally conscious state ; Ethics ; Attitudes ; Survey
• 刊名：Neuroethics
• 出版年：2013
• 出版时间：April 2013
• 年：2013
• 卷：6
• 期：1
• 页码：37-50
• 全文大小：257KB
• 参考文献：1. Ekman, Paul, and Wallace V. Friesen. 1971. Constants across cultures in the face and emotion. / Journal of Personality and Social Psychology 17(2): 124-29. CrossRef
  2. Laureys, Steven, Gastone G. Celesia, Fran?ois Cohadon, Jan Lavrijsen, Jose Leon-Carrrion, Walter G. Sannita, Leon Sazbon, et al. 2010. Unresponsive wakefulness syndrome: A new name for the vegetative state or apallic syndrome. / BMC Medicine 8(1): 68. doi:10.1186/1741-7015-8-68 . CrossRef
  3. Jennett, Bryan, and Fred Plum. 1972. Persistent vegetative state after brain damage. A syndrome in search of a name. / Lancet 1(7753): 734-37. CrossRef
  4. Giacino, Joseph T., Stephen Ashwal, Nancy Childs, Ronald Cranford, Bryan Jennett, Douglas I. Katz, James P. Kelly, et al. 2002. The minimally conscious state: Definition and diagnostic criteria. / Neurology 58(3): 349-53. CrossRef
  5. Bruno, Marie-Aurèlie, Audrey Vanhaudenhuyse, Aurore Thibaut, Gustave Moonen, and Steven Laureys. 2011. From unresponsive wakefulness to minimally conscious PLUS and functional locked-in syndromes: Recent advances in our understanding of disorders of consciousness. / Journal of Neurology 258(7): 1373-384. doi:10.1007/s00415-011-6114-x . CrossRef
  6. Demertzi, Athena, Caroline Schnakers, Didier Ledoux, Camille Chatelle, Marie-Aurèlie Bruno, Audrey Vanhaudenhuyse, Mélanie Boly, Gustave Moonen, and Steven Laureys. 2009. Different beliefs about pain perception in the vegetative and minimally conscious states: A European survey of medical and paramedical professionals. / Progress in Brain Research 177: 329-38. doi:10.1016/S0079-6123(09)17722-1 . CrossRef
  7. Schnakers, Caroline, and Nathan D. Zasler. 2007. Pain assessment and management in disorders of consciousness. / Current Opinion in Neurology 20(6): 620-26. CrossRef
  8. Farisco, Michele. 2011. The ethical pain. / Neuroethics:1-12. doi:10.1007/s12152-011-9111-y .
  9. Demertzi, Athena, Audrey Vanhaudenhuyse, Marie-Aurèlie Bruno, Caroline Schnakers, Mélanie Boly, Pierre Boveroux, Pierre Maquet, Gustave Moonen, and Steven Laureys. 2008. Is there anybody in there? Detecting awareness in disorders of consciousness. / Expert Review in Neurotherapeutics 8(11): 1719-730. CrossRef
  10. The Multi-Society Task Force on PVS. 1994. Medical aspects of the persistent vegetative state (2). / The New England Journal of Medicine 330(22): 1572-579. CrossRef
  11. Royal College of Physicians. 2003. The vegetative state: Guidance on diagnosis and management. / Clinical Medicine 3(3): 249-54. medicine.3-3-249">CrossRef
  12. Cassel, Eric J. 1982. The nature of suffering and the goals of medicine. / The New England Journal of Medicine 306(11): 639-45. CrossRef
  13. Demertzi, Athena, Steven Laureys, and Marie-Aurèlie Bruno. 2011. The ethics in disorders of consciousness. In / Annual Update in Intensive Care and Emergency Medicine, ed. J.L. Vincent, 675-82. Berlin: Springer.
  14. Council on Scientific Affairs and Council on Ethical and Judicial Affairs. 1990. Persistent vegetative state and the decision to withdraw or withhold life support. / The Journal of the American Medical Association 263(3): 426-30. ma.1990.03440030113032">CrossRef
  15. Demertzi, Athena, Didier Ledoux, Marie-Aurèlie Bruno, Audrey Vanhaudenhuyse, Olivia Gosseries, Andrea Soddu, Caroline Schnakers, Gustave Moonen, and Steven Laureys. 2011. Attitudes towards end-of-life issues in disorders of consciousness: A European survey. / Journal of Neurology 258(6): 1058-065. doi:10.1007/s00415-010-5882-z . CrossRef
  16. Wilkinson, Dominic J., Guy Kahane, Malcolm Horne, and Julian Savulescu. 2009. Functional neuroimaging and withdrawal of life-sustaining treatment from vegetative patients. / Journal of Medical Ethics 35(8): 508-11. doi:10.1136/jme.2008.029165 . me.2008.029165">CrossRef
  17. International Association for the Study of Pain. 1994. / Classification of Chronic Pain: descriptions of chronic pain syndromes and definitions of pain terms. Task force on taxonomy. Seatle: IASP Press.
  18. Loeser, John D., and Rolf-Detlef Treede. 2008. The Kyoto protocol of IASP basic pain terminology. / Pain 137(3): 473-77. doi:10.1016/j.pain.2008.04.025 . CrossRef
  19. Laureys, Steven. 2005. Science and society: Death, unconsciousness and the brain. / Nature reviews Neuroscience 6(11): 899-09. CrossRef
  20. The Medical Task Force on Anencephaly. 1990. The infant with anencephaly. / The New England Journal of Medicine 322(10): 669-74. CrossRef
  21. Payne, S. Kirk, and Robert M. Taylor. 1997. The persistent vegetative state and anencephaly: Problematic paradigms for discussing futility and rationing. / Seminars in Neurology 17(3): 257-63. CrossRef
  22. Halliburton, James R. 1998. Awareness during general anesthesia: New technology for an old problem. / CRNA: The Clinical Forum for Nurse Anesthetists 9(2): 39-3.
  23. Schnakers, Caroline, Marie-Elisabeth Faymonville, and Steven Laureys. 2009. Ethical implications: Pain, coma, and related disorders. In / Encyclopedia of consciousness, ed. W.P. Banks, 243-50. Oxford: Elsevier. CrossRef
  24. Schnakers, Caroline, Camille Chatelle, Audrey Vanhaudenhuyse, Steve Majerus, Didier Ledoux, Mélanie Boly, Marie-Aurèlie Bruno, et al. 2010. The Nociception Coma Scale: A new tool to assess nociception in disorders of consciousness. / Pain 148(2): 215-19. doi:10.1016/j.pain.2009.09.028 . CrossRef
  25. Giacino, Joseph T., Kathleen Kalmar, and John Whyte. 2004. The JFK Coma Recovery Scale-Revised: Measurement characteristics and diagnostic utility. / Archives of physical medicine and rehabilitation 85(12): 2020-029. mr.2004.02.033">CrossRef
  26. Magee, Wendy L. 2005. Music therapy with patients in low awareness states: Approaches to assessment and treatment in multidisciplinary care. / Neuropsychological Rehabilitation 15(3-): 522-36. doi:10.1080/09602010443000461 . CrossRef
  27. Laureys, Steven, and Mélanie Boly. 2008. The changing spectrum of coma. / Nature Clinical Practice Neurology 4(10): 544-46. CrossRef
  28. Laureys, Steven, Fabien Perrin, Marie-Elisabeth Faymonville, Caroline Schnakers, Mélanie Boly, Valerie Bartsch, Steve Majerus, Gustave Moonen, and Pierre Maquet. 2004. Cerebral processing in the minimally conscious state. / Neurology 63(5): 916-18. CrossRef
  29. Schiff, Nicholas D., Diana Rodriguez-Moreno, A. Kamal, K.H. Kim, Joseph T. Giacino, Fred Plum, and Joy Hirsch. 2005. fMRI reveals large-scale network activation in minimally conscious patients. / Neurology 64(3): 514-23. CrossRef
  30. Bekinschtein, Tristan A., Ramon Leiguarda, Jorge Armony, Adrian M. Owen, Silvina Carpintiero, Jorge Niklison, Lisa Olmos, Lucas Sigman, and Facundo F. Manes. 2004. Emotion processing in the minimally conscious state. / Journal of Neurology, Neurosurgery, and Psychiatry 75(5): 788. CrossRef
  31. Zhu, Jianhong, Xuehai Wu, Liang Gao, Ying Mao, Ping Zhong, Weijun Tang, and Liangfu Zhou. 2009. Cortical activity after emotional visual stimulation in minimally conscious state patients. / Journal of Neurotrauma 26(5): 677-88. doi:10.1089/neu.2008.0691 . CrossRef
  32. de Jong, Bauke M., Antoon T. Willemsen, and Anne M. Paans. 1997. Regional cerebral blood flow changes related to affective speech presentation in persistent vegetative state. / Clinical Neurology and Neurosurgery 99(3): 213-16. CrossRef
  33. Llinas, Rodolfo, and Urs Ribary. 2001. Consciousness and the brain. The thalamocortical dialogue in health and disease. / Annals New York Academy of Sciences 929: 166-75. CrossRef
  34. Machado, Calixto, Mario Estevez, Joel Gutierrez, Carlos Beltran, Yazmina Machado, Yanin Machado, Mauricio Chinchilla, and Jesus Perez-Nellar. 2011. Recognition of the mom’s voice with an emotional content in a PVS patient. / Clinical Neurophysiology 122(5): 1059-060. doi:10.1016/j.clinph.2010.08.022 . author reply 1061-1052. CrossRef
  35. Riganello, Francesco, Antonio Candelieri, Maria Quintieri, Domenico Conforti, and Giuliano Dolce. 2010. Heart rate variability: An index of brain processing in vegetative state? An artificial intelligence, data mining study. / Clinical Neurophysiology 121(12): 2024-034. doi:10.1016/j.clinph.2010.05.010 . CrossRef
  36. Eickhoff, Simon B., Manuel Dafotakis, Christian Grefkes, Tony St?cker, N. Jon Shah, Alfons Schnitzler, Karl Zilles, and Mario Siebler. 2008. fMRI reveals cognitive and emotional processing in a long-term comatose patient. / Experimental Neurology 214(2): 240-46. doi:10.1016/j.expneurol.2008.08.007 . CrossRef
  37. Laureys, Steven, Frédéric Pellas, Philippe Van Eeckhout, Sofiane Ghorbel, Caroline Schnakers, Fabien Perrin, Jacques Berre, et al. 2005. The locked-in syndrome: What is it like to be conscious but paralyzed and voiceless? / Progress in Brain Research 150: 495-11. CrossRef
  38. Kotchoubey, Boris, Jochen Kaiser, Vladimir Bostanov, Werner Lutzenberger, and Niels Birbaumer. 2009. Recognition of affective prosody in brain-damaged patients and healthy controls: A neurophysiological study using EEG and whole-head MEG. / Cognitive, Affective & Behavioral Neuroscience 9(2): 153-67. doi:10.3758/CABN.9.2.153 . CrossRef
  39. Price, Donald D. 2000. Psychological and neural mechanisms of the affective dimension of pain. / Science 288(5472): 1769-772. CrossRef
  40. Tracey, Irene. 2005. Nociceptive processing in the human brain. / Current Opinion in Neurobiology 15(4): 478-87. doi:10.1016/j.conb.2005.06.010 . CrossRef
  41. Vogt, Brent A., Robert W. Sikes, and Leslie J. Vogt. 1993. Anterior cingulate cortex and the medical pain system. In / Neurobiology of cingulate cortex and limbic thalamus, ed. Brent A. Vogt and Michael Gabriel, 313-44. Boston: Birkhauser.
  42. Laureys, Steven, Marie-Elisabeth Faymonville, Philippe Peigneux, Pierre Damas, Bernard Lambermont, Guy Del Fiore, Christian Degueldre, et al. 2002. Cortical processing of noxious somatosensory stimuli in the persistent vegetative state. / Neuroimage 17(2): 732-41. mg.2002.1236">CrossRef
  43. Baars, Bernard, Thomas Z. Ramsoy, and Steven Laureys. 2003. Brain, conscious experience and the observing self. / Trends in Neurosciences 26(12): 671-75. CrossRef
  44. Laureys, Steven. 2005. The neural correlate of (un)awareness: Lessons from the vegetative state. / Trends in Cognitive Sciences 9(12): 556-59. CrossRef
  45. Kassubek, Jan, Freimut D. Juengling, Thomas Els, Joachim Spreer, Martin Herpers, Thomas Krause, Ernst Moser, and Carl H. Lucking. 2003. Activation of a residual cortical network during painful stimulation in long-term postanoxic vegetative state: A 15O-H2O PET study. / Journal of the Neurological Sciences 212(1-): 85-1. CrossRef
  46. Boly, Mélanie, Marie-Elisabeth Faymonville, Caroline Schnakers, Philippe Peigneux, Bernard Lambermont, Christophe Phillips, Patrizio Lancellotti, et al. 2008. Perception of pain in the minimally conscious state with PET activation: An observational study. / Lancet Neurology 7(11): 1013-020. CrossRef
  47. Boly, Mélanie, Marie-Elisabeth Faymonville, Philippe Peigneux, Bernard Lambermont, Fran?ois Damas, Andre Luxen, Maurice Lamy, Gustave Moonen, Pierre Maquet, and Steven Laureys. 2005. Cerebral processing of auditory and noxious stimuli in severely brain injured patients: differences between VS and MCS. / Neuropsycholigal Rehabilitation 15(3-): 283-89. CrossRef
  48. Berridge, Kent, and Morten Kringelbach. 2011. Building a neuroscience of pleasure and well-being. / Psychology of Well-Being 1(1): 1-6. doi:10.1186/2211-1522-1-3 .
  49. Demertzi, Athena, Olivia Gosseries, Didier Ledoux, Steven Laureys, and Marie-Aurèlie Bruno. in press. Quality of life and end-of-life decisions after brain injury. In / Rethinking disability and quality of life: a global perspective, eds. Narelle Warren, and Lenore Manderson. Social Indicators Research Dordrecht: Springer.
  50. Bruno, Marie-Aurèlie, Jan L. Bernheim, Didier Ledoux, Frédéric Pellas, Athena Demertzi, and Steven Laureys. 2011. A survey on self-assessed well-being in a cohort of chronic locked-in syndrome patients: happy majority, miserable minority. / British Medical Journal Open:1-.
  51. Quill, Timothy E. 2005. Terri Schiavo—a tragedy compounded. / The New England Journal of Medicine 352(16): 1630-633. CrossRef
  52. Racine, Eric, Rakesh Amaram, Matthew Seidler, Marta Karczewska, and Judy Illes. 2008. Media coverage of the persistent vegetative state and end-of-life decision-making. / Neurology 71(13): 1027-032. doi:10.1212/01.wnl.0000320507.64683.ee . CrossRef
  53. Tresch, Donald D., Farrol H. Sims, Edmund H. Duthie Jr., and Michael D. Goldstein. 1991. Patients in a persistent vegetative state attitudes and reactions of family members. / Journal of the American Geriatrics Society 39(1): 17-1.
  54. Platts-Mills, T.F., D.A. Esserman, D.L. Brown, A.V. Bortsov, P.D. Sloane, and S.A. McLean. 2011. Older US emergency department patients are less likely to receive pain medication than younger patients: Results from a national survey. / Annals of Emergency Medicine. doi:10.1016/j.annemergmed.2011.09.014 .
  55. Fins, Joseph J. 2006. Affirming the right to care, preserving the right to die: Disorders of consciousness and neuroethics after Schiavo. / Palliative and Supportive Care 4(2): 169-78.
  56. Ahronheim, Judith C., and M. Rose Gasner. 1990. The sloganism of starvation. / Lancet 335(8684): 278-79. CrossRef
  57. Payne, S.Kirk, Robert M. Taylor, Carol Stocking, and Greg A. Sachs. 1996. Physicians-attitudes about the care of patients in the persistent vegetative state: A national survey. / Annals of Internal Medicine 125(2): 104-10.
  58. Daroff, Robert B. 1990. The American Neurological Association survey results on PVS. Paper presented at the 115th Annual Meeting of the American Neurological Association, Atlanta, GA, October 14-17.
  59. Childs, Nancy L., Walt N. Mercer, and Helen W. Childs. 1993. Accuracy of diagnosis of persistent vegetative state. / Neurology 43(8): 1465-467. CrossRef
  60. Schnakers, Caroline, Audrey Vanhaudenhuyse, Joseph Giacino, Mandredi Ventura, Mélanie Boly, Steve Majerus, Gustave Moonen, and Steven Laureys. 2009. Diagnostic accuracy of the vegetative and minimally conscious state: Clinical consensus versus standardized neurobehavioral assessment. / BMC Neurology 9: 35. CrossRef
  61. Andrews, Keith, Lesley Murphy, Ros Munday, and Clare Littlewood. 1996. Misdiagnosis of the vegetative state: Retrospective study in a rehabilitation unit. / British Medical Journal (Clinical Research Ed.) 313(7048): 13-6. mj.313.7048.13">CrossRef
  62. Young, Bryan, Warren Blume, and Abbyann Lynch. 1989. Brain death and the persistent vegetative state: Similarities and contrasts. / Canadian Journal of Neurological Sciences 16(4): 388-93.
  63. Youngner, Stuart J., Seth S. Landefeld, Claudia J. Coulton, Barbara W. Juknialis, and Mark Leary. 1989. Brain death and organ retrieval. A cross-sectional survey of knowledge and concepts among health professionals. / The Journal of the American Medical Association 261(15): 2205-210.
  64. Siminoff, Laura A., Christopher Burant, and Stuart J. Youngner. 2004. Death and organ procurement: Public beliefs and attitudes. / Kennedy Institute of Ethics Journal 14(3): 217-34. CrossRef
  65. Asch, David A., Judy A. Shea, M.Kathryn Jedrziewski, and Charles L. Bosk. 1997. The limits of suffering: Critical care nurses-views of hospital care at the end of life. / Social Science and Medicine 45(11): 1661-668. CrossRef
  66. Festic, Emir, Michael E. Wilson, Ognjen Gajic, Gavin D. Divertie, and Jeffrey T. Rabatin. 2011. Perspectives of physicians and nurses regarding end-of-life care in the intensive care unit. / Journal of Intensive Care Medicine. doi:10.1177/0885066610393465 .
  67. Racine, Eric, Marie-Josee Dion, Christine A.C. Wijman, Judy Illes, and Maarten G. Lansberg. 2009. Profiles of neurological outcome prediction among intensivists. / Neurocritical Care 11(3): 345-52. doi:10.1007/s12028-009-9225-9 . CrossRef
  68. Randolph, Adrienne G., Mary B. Zollo, Robert S. Wigton, and Timothy S. Yeh. 1997. Factors explaining variability among caregivers in the intent to restrict life-support interventions in a pediatric intensive care unit. / Critical Care Medicine 25(3): 435-39. CrossRef
  69. Rocker, Graeme, Deborah Cook, Peter Sjokvist, Bruce Weaver, Simon Finfer, Ellen McDonald, John Marshall, et al. 2004. Clinician predictions of intensive care unit mortality. / Critical Care Medicine 32(5): 1149-154. CrossRef
  70. Rebagliato, Marisa, Marina Cuttini, Lara Broggin, István Berbik, Umberto de Vonderweid, Gesine Hansen, Monique Kaminski, et al. 2000. Neonatal end-of-life decision making: Physicians-attitudes and relationship with self-reported practices in 10 European countries. / The Journal of the American Medical Association 284(19): 2451-459. ma.284.19.2451">CrossRef
  71. Marcin, James P., Murray M. Pollack, Kantilal M. Patel, Bruce M. Sprague, and Urs E. Ruttimann. 1999. Prognostication and certainty in the pediatric intensive care unit. / Pediatrics 104(4 Pt 1): 868-73. CrossRef
  72. Demertzi, Athena, Charlene Liew, Didier Ledoux, Marie-Aurèlie Bruno, Michael Sharpe, Steven Laureys, and Adam Zeman. 2009. Dualism persists in the science of mind. / Annals of the New York Academy of Sciences 1157: 1-. CrossRef
  73. Jennett, Bryan. 2002. / The vegetative state. Medical facts, ethical and legal dilemmas. Cambridge: Cambridge University Press. CrossRef
  74. Christakis, Nicholas A., and David A. Asch. 1995. Physician characteristics associated with decisions to withdraw life support. / American Journal of Public Health 85(3): 367-72. CrossRef
  75. Sprung, Charles L., Simon L. Cohen, Peter Sjokvist, Mario Baras, Hans-Henrik Bulow, Seppo Hovilehto, Didier Ledoux, et al. 2003. End-of-life practices in European intensive care units: The Ethicus Study. / The Journal of the American Medical Association 290(6): 790-97. ma.290.6.790">CrossRef
  76. Racine, Eric, Catherine Rodrigue, James L. Bernat, Richard Riopelle, and Sam D. Shemie. 2010. Observations on the ethical and social aspects of disorders of consciousness. / The Canadian Journal of Neurological Sciences 37(6): 758-68.
  77. Stumpf, Samuel E. 1986. A comment on “Helen- / Southern Medical Journal 79(9): 1057-058. CrossRef
  78. Ropper, Allan H. 2010. Cogito ergo sum by MRI. / The New England Journal of Medicine 362(7): 648-49. doi:10.1056/NEJMe0909667 .
  79. Kahane, Guy, and Julian Savulescu. 2009. Brain damage and the moral significance of consciousness. / The Journal of Medicine and Philosophy 34(1): 6-6. doi:10.1093/jmp/jhn038 .
  80. Singer, Peter. 2011. / Practical Ethics. Third Ed. Cambridge: Cambridge University Press.
  81. Veatch, Robert M. 2005. The death of whole-brain death: The plague of the disaggregators, somaticists, and mentalists. / The Journal of Medicine and Philosophy 30(4): 353-78. doi:10.1080/03605310591008504 .
  82. Fletcher, Joseph. 1979. / Humanhood: Essays in biomedical ethics. New York: Prometheus Books.
  83. Macklin, Ruth 1983. Personhood in the bioethics literature. / The Milbank Memorial Fund quarterly. Health and Society 61(1): 35-7.
  84. Racine, Eric, Ofek Bar-Ilan, and Judy Illes. 2005. fMRI in the public eye. / Nature Reviews Neuroscience 6(2): 159-64. doi:10.1038/nrn1609 . CrossRef
  85. Glannon, Walter 2009. Our brains are not us. / Bioethics 23(6): 321-29. doi:10.1111/j.1467-8519.2009.01727.x .
  86. Racine, Eric, Sarah Waldman, Jarett Rosenberg, and Judy Illes. 2010. Contemporary neuroscience in the media. / Social Science and Medicine 71(4): 725-33. doi:10.1016/j.socscimed.2010.05.017 . med.2010.05.017">CrossRef
  87. McCabe, David P., and Alan D. Castel. 2008. Seeing is believing: The effect of brain images on judgments of scientific reasoning. / Cognition 107(1): 343-52. doi:10.1016/j.cognition.2007.07.017 . CrossRef
  88. O’Connell, Garret, Janet De Wilde, Jane Haley, Kirsten Shuler, Burkhard Schafer, Peter Sandercock, and Joanna M. Wardlaw. 2011. The brain, the science and the media. The legal, corporate, social and security implications of neuroimaging and the impact of media coverage. / EMBO Reports 12(7): 630-36. doi:10.1038/embor.2011.115 . mbor.2011.115">CrossRef
  89. Weisberg, Deena Skolnick, Frank C. Keil, Joshua Goodstein, Elizabeth Rawson, and Jeremy R. Gray. 2008. The seductive allure of neuroscience explanations. / Journal of Cognitive Neuroscience 20(3): 470-77. doi:10.1162/jocn.2008.20040 . CrossRef
  
• 作者单位：A. Demertzi (1) (2)
  E. Racine (3) (4) (5)
  M-A. Bruno (1) (2)
  D. Ledoux (1) (6)
  O. Gosseries (1) (2)
  A. Vanhaudenhuyse (1) (2)
  M. Thonnard (1) (2)
  A. Soddu (1) (2)
  G. Moonen (2) (7)
  S. Laureys (1) (2)
  
  1. Coma Science Group, Cyclotron Research Center, University of Liège, Liège, Belgium
  2. CHU Neurology Department, University Hospital of Liège, Liège, Belgium
  3. Neuroethics Research Unit, Institut de recherches cliniques de Montréal, Montreal, Canada
  4. Department of Medicine and Department of Social and Preventive Medicine, Université de Montréal, Montreal, Canada
  5. Departments of Neurology and Neurosurgery, Medicine & Biomedical Ethics Unit, McGill University, Montreal, Canada
  6. CHU Department of Intensive Care, University of Liège, Liège, Belgium
  7. University of Liège, Liège, Belgium
  
• ISSN：1874-5504

文摘

Pain, suffering and positive emotions in patients in vegetative state/unresponsive wakefulness syndrome (VS/UWS) and minimally conscious states (MCS) pose clinical and ethical challenges. Clinically, we evaluate behavioural responses after painful stimulation and also emotionally-contingent behaviours (e.g., smiling). Using stimuli with emotional valence, neuroimaging and electrophysiology technologies can detect subclinical remnants of preserved capacities for pain which might influence decisions about treatment limitation. To date, no data exist as to how healthcare providers think about end-of-life options (e.g., withdrawal of artificial nutrition and hydration) in the presence or absence of pain in non-communicative patients. Here, we aimed to better clarify this issue by re-analyzing previously published data on pain perception (Prog Brain Res 2009 177, 329-8) and end-of-life decisions (J Neurol 2010 258, 1058-5) in patients with disorders of consciousness. In a sample of 2259 European healthcare professionals we found that, for VS/UWS more respondents agreed with treatment withdrawal when they considered that VS/UWS patients did not feel pain (77%) as compared to those who thought VS/UWS did feel pain (59%). This interaction was influenced by religiosity and professional background. For MCS, end-of-life attitudes were not influenced by opinions on pain perception. Within a contemporary ethical context we discuss (1) the evolving scientific understandings of pain perception and their relationship to existing clinical and ethical guidelines; (2) the discrepancies of attitudes within (and between) healthcare providers and their consequences for treatment approaches, and (3) the implicit but complex relationship between pain perception and attitudes toward life-sustaining treatments.