Bhardwaj Twisha, Edlow Brian L, Young Michael J
Center for Neurotechnology and Neurorecovery, Department of Neurology, Massachusetts General Hospital and Harvard Medical School, 55 Fruit St., Boston, MA, 02114, USA.
Athinoula A. Martinos Center for Biomedical Imaging, Massachusetts General Hospital, Charlestown, MA, USA.
Neurocrit Care. 2024 Oct 30. doi: 10.1007/s12028-024-02147-3.
Although evaluation of disorders of consciousness (DoC) following brain injury has traditionally relied on bedside behavioral examination, advances in neurotechnology have elucidated novel approaches to detecting and predicting recovery of consciousness. Professional society guidelines now recommend that clinicians integrate these neurotechnologies into clinical practice as part of multimodal evaluations for some patients with DoC but have not crafted concrete protocols for this translation. Little is known about the experiences and ethical perspectives held by key stakeholder groups around the clinical implementation of advanced neurotechnologies to detect and predict recovery of consciousness. Recognizing this knowledge gap, the Data-Driven Neuroethics for Consciousness Detection (DECODE) survey examined clinicians' perspectives on advanced neurotechnologies for DoC care, including access to and rates of adoption, perceived utility, facilitators and barriers to adoption in clinical settings, ethical considerations surrounding clinical implementation, and challenges encountered in ensuring care for patients with acute and prolonged DoC. Mixed-methods analysis including qualitative analysis, grounded theory methodology, and ethical analysis was employed to assess responses and key themes. Ninety-two clinicians consented to the survey. More than 70% believed that standard bedside behavioral examination is insufficient, and nearly 60% viewed advanced neurotechnologies as integral in optimal DoC evaluation. Training gaps and limited institutional infrastructure were identified as salient barriers to clinical implementation. Thematic analysis revealed concerns about the interpretation of results, impact on surrogates, and validity of test results. Ethical themes of prognostic uncertainty, nihilism, and access also permeated multiple domains. Considerations surrounding access, knowledge base, results interpretation, and communication with surrogates are cross-cutting ethical threads shaping the clinical translation of advanced neurotechnologies for DoC. These components represent opportunities for implementation science work focused on democratizing access to neurotechnologies, educating clinicians on the use of novel techniques and interpretation of results, conducting multisite validation studies, and standardizing approaches to communicating test results.
尽管传统上对脑损伤后意识障碍（DoC）的评估依赖于床边行为检查，但神经技术的进步已经阐明了检测和预测意识恢复的新方法。专业协会指南现在建议临床医生将这些神经技术整合到临床实践中，作为对一些DoC患者进行多模式评估的一部分，但尚未制定具体的实施方案。对于关键利益相关者群体在临床应用先进神经技术检测和预测意识恢复方面的经验和伦理观点知之甚少。认识到这一知识差距，意识检测数据驱动神经伦理学（DECODE）调查研究了临床医生对用于DoC护理的先进神经技术的看法，包括获取情况和采用率、感知效用、临床环境中采用的促进因素和障碍、临床应用中的伦理考量，以及在确保对急性和长期DoC患者的护理中遇到的挑战。采用包括定性分析、扎根理论方法和伦理分析在内的混合方法分析来评估调查结果和关键主题。92名临床医生同意参与调查。超过70%的人认为标准的床边行为检查不够充分，近60%的人认为先进神经技术是最佳DoC评估中不可或缺的一部分。培训差距和有限的机构基础设施被确定为临床应用的突出障碍。主题分析揭示了对结果解释、对替代决策者的影响以及测试结果有效性的担忧。预后不确定性、虚无主义和获取机会等伦理主题也贯穿多个领域。围绕获取机会、知识库、结果解释以及与替代决策者沟通的考量是影响先进神经技术在DoC临床应用的交叉伦理线索。这些因素为实施科学工作提供了机会，重点是使神经技术的获取民主化、培训临床医生使用新技术和解释结果、开展多中心验证研究以及规范测试结果的沟通方式。
