Heinonen Gregory A, Carmona Jerina C, Grobois Lauren, Kruger Lucie S, Velazquez Angela, Vrosgou Athina, Kansara Vedant B, Shen Qi, Egawa Satoshi, Cespedes Lizbeth, Yazdi Mariam, Bass Danielle, Saavedra Ana Bolanos, Samano Daniel, Ghoshal Shivani, Roh David, Agarwal Sachin, Park Soojin, Alkhachroum Ayham, Dugdale Lydia, Claassen Jan
Department of Neurology, Columbia University Irving Medical Center, New York, NY, USA.
NewYork-Presbyterian Hospital, New York, NY, USA.
Neurocrit Care. 2024 Oct 23. doi: 10.1007/s12028-024-02145-5.
Prognostication of patients with acute disorders of consciousness is imprecise but more accurate technology-supported predictions, such as cognitive motor dissociation (CMD), are emerging. CMD refers to the detection of willful brain activation following motor commands using functional magnetic resonance imaging or machine learning-supported analysis of the electroencephalogram in clinically unresponsive patients. CMD is associated with long-term recovery, but acceptance by surrogates and health care professionals is uncertain. The objective of this study was to determine receptiveness for CMD to inform goals of care (GoC) decisions and research participation among health care professionals and surrogates of behaviorally unresponsive patients.
This was a two-center study of surrogates of and health care professionals caring for unconscious patients with severe neurological injury who were enrolled in two prospective US-based studies. Participants completed a 13-item survey to assess demographics, religiosity, minimal acceptable level of recovery, enthusiasm for research participation, and receptiveness for CMD to support GoC decisions.
Completed surveys were obtained from 196 participants (133 health care professionals and 63 surrogates). Across all respondents, 93% indicated that they would want their loved one or the patient they cared for to participate in a research study that supports recovery of consciousness if CMD were detected, compared to 58% if CMD were not detected. Health care professionals were more likely than surrogates to change GoC with a positive (78% vs. 59%, p = 0.005) or negative (83% vs. 59%, p = 0.0002) CMD result. Participants who reported religion was the most important part of their life were least likely to change GoC with or without CMD. Participants who identified as Black (odds ratio [OR] 0.12, 95% confidence interval [CI] 0.04-0.36) or Hispanic/Latino (OR 0.39, 95% CI 0.2-0.75) and those for whom religion was the most important part of their life (OR 0.18, 95% CI 0.05-0.64) were more likely to accept a lower minimum level of recovery.
Technology-supported prognostication and enthusiasm for clinical trial participation was supported across a diverse spectrum of health care professionals and surrogate decision-makers. Education for surrogates and health care professionals should accompany integration of technology-supported prognostication.
急性意识障碍患者的预后评估并不精确，但诸如认知运动分离（CMD）等更精确的技术支持预测方法正在出现。CMD是指在临床无反应的患者中，利用功能磁共振成像或机器学习支持的脑电图分析，检测运动指令后有意的脑激活。CMD与长期恢复相关，但代理人和医疗保健专业人员对其接受程度尚不确定。本研究的目的是确定医疗保健专业人员和行为无反应患者的代理人对CMD用于指导护理目标（GoC）决策和参与研究的接受程度。
这是一项针对照顾严重神经损伤昏迷患者的代理人和医疗保健专业人员的双中心研究，这些患者参加了两项美国前瞻性研究。参与者完成了一项包含13个条目的调查，以评估人口统计学、宗教信仰、最低可接受的恢复水平、参与研究的热情以及对CMD支持GoC决策的接受程度。
共获得196名参与者（133名医疗保健专业人员和63名代理人）的完整调查结果。在所有受访者中，93%表示，如果检测到CMD，他们希望自己所爱的人或他们照顾的患者参与支持意识恢复的研究；而如果未检测到CMD，这一比例为58%。与代理人相比，医疗保健专业人员更有可能根据CMD阳性（78%对59%，p = 0.005）或阴性（83%对59%，p = 0.0002）结果改变GoC。报告宗教是其生活中最重要部分的参与者，无论有无CMD，改变GoC的可能性最小。将自己认定为黑人（优势比[OR]0.12，95%置信区间[CI]0.04 - 0.36）或西班牙裔/拉丁裔（OR 0.39，95%CI 0.2 - 0.75）的参与者，以及那些认为宗教是其生活中最重要部分的参与者（OR 0.18，95%CI 0.05 - 0.64），更有可能接受较低的最低恢复水平。
各种医疗保健专业人员和替代决策者都支持技术支持的预后评估和参与临床试验的热情。在整合技术支持的预后评估时，应同时对代理人和医疗保健专业人员进行教育。
