Prognostication and Trajectories of Recovery in Disorders of Consciousness

Acquired brain injury, especially severe brain injury, is a chronic medical condition. There is a trove of information on acute care management and large-scale studies; however, there is a gap in research studies on prognostication and trajectory analysis in postacute care and long-term outcomes. Major challenges to obtaining this data include a lack of large-scale data sources outside of those that have participated in acute inpatient rehabilitation, early WoLST, varied recovery trajectories, and inequalities in access to care.Furthermore, there is a paradox between the current state of medicine and the needs of the special population with DoC. Health-care systems are often focused on meeting metrics and quality indicators, such as decreased length of stay and morbidity/mortality, and oftentimes, reimbursement and financial health of the institution are tied to these metrics. Guidelines for the care of persons with severe brain injury require time, resources, and knowledge of the population and the outcomes possible. In summation, the paucity of national guidelines/recommendations suggests an international need for standardization of admission criteria (which may in part be driven by resource availability and monetary allocation), clinical and instrumental diagnostic tools and prognostic protocols that should be developed, endorsed, and disseminated.Finally, but remarkably important, there are also implicit biases and differing perspectives on what constitutes meaningful recovery and quality of life.1 This raises a question that is difficult to answer, especially early after injury. What is quality of life? Is recovery of consciousness enough of a goal? Emerging from a DoC state is not a linear event. Patients do not emerge predictively and delayed emergence is neither uncommon nor does it indicate a poor outcome from a traumatic brain injury. As health-care professionals, evidence-based prognostic expectations need to be considered but we also must consider the interplay of personal histories, family dynamics, injury severity, acceptance of disability, health-care coverage, and societal socioeconomics.

Automated summary

Acquired brain injury, especially severe brain injury, is a chronic medical condition that lacks research studies on postacute care and long-term outcomes. There is a need for standardized admission criteria, diagnostic tools, and prognostic protocols. Furthermore, healthcare systems should consider personalized factors and different perspectives on meaningful recovery and quality of life.