Ethics and the Unresponsive Patient
Tuesday, September 20, 2016
12:00pm - 1:15pm
Location: Johns Hopkins Hospital
Sheik Zayed Tower
Zayed 2117 (Arcade)
Lunch will be provided
A 26-year-old man was admitted to the Johns Hopkins Neuroscience Critical Care Unit (NCCU) for head injuries after a motor vehicle accident. He was previously healthy and was pursuing a law degree at a local university. His car struck a tree late at night. On admission, the patient was found to be in a coma, and the CT scan of the head demonstrated multifocal brain injuries. Over the next days he developed refractory intracranial hypertension and was taken to the operating room for decompressive craniectomy. The patient’s course was complicated by aspiration pneumonia, adult respiratory distress syndrome (ARDS) and septic shock. He suffered cardiac arrest requiring cardiopulmonary resuscitation. The patient remained unresponsive throughout his stay. Brain MRI showed diffuse axonal injury. Electroencephalography (EEG) showed no evidence of seizures. Somatosensory evoked potentials were inconclusive. He was discharged to a rehabilitation for coma stimulation therapy.
Questions of family members:
1. Will the patient survive, or can we do anything to promote recovery?
2. Can the patient hear us or feel pain?
3. Are there any tests to probe awareness?
4. How long will the patient stay like this? If the patient wakes up, what will he/she be like in the future?
5. Should we “pull the plug”?
Questions of healthcare team members:
1. Is it OK to use noxious stimuli to increase sensitivity/specificity of the neurologic assessment?
2. What is the prognosis for neurologic recovery?
3. Which tests should be obtained to support prognosis?
4. Is the care medically ineffective/futile?
5. What are the criteria for brain death?
Questions of researchers:
1. What are the ethical boundaries for enrolling patients with disorders of consciousness in research studies?
1. Facts about the Vegetative and Minimally Conscious States after Severe Brain Injury
2. Brain Death and Disorders of Consciousness. Current Biology. 2016 Jul 11;26(13).
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Robert D. Stevens, MD
Associate Professor of Anesthesiology, Neurology, Neurosurgery, and Radiology, Johns Hopkins University School of Medicine; Attending Physician, Neuroscience Critical Care, Johns Hopkins Hospital
Peter Kaplan, FRCP
Professor of Neurology, Johns Hopkins University School of Medicine; Director of Epilepsy and EEG, Johns Hopkins Bayview Medical Center
Beth Slomine, PhD
Associate Professor of Psychiatry and Behavioral Sciences, Johns Hopkins University School of Medicine; Co-director of the Center for Brain Injury Recovery, Kennedy Krieger Institute
Adam Schiavi, MD, PhD
Assistant Professor of Anesthesiology and Neurology, Johns Hopkins University School of Medicine; Attending Physician, Neuroscience Critical Care, Johns Hopkins Hospital
Kate Bechtold, PhD
Associate Professor of Physical Medicine and Rehabilitation Program, Johns Hopkins University School of Medicine; Director Brain and Stroke Rehabilitation Program, Johns Hopkins Hospital
The Rev. John V.P.R. Ponnala, MA, BD, BCC
Family Advocate Coordinator, Department of Spiritual Care and Chaplaincy, Johns Hopkins Hospital
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Ethics for Lunch: