Lancet Neurol：病人有高比率被误诊为慢性意识障碍

新工具证实病人有高比率被误诊为慢性意识障碍(chronic disorders of consciousness)，如植物人状态(vegetative state)。越来越多的病人家庭想要使用这些新的技术来进行诊断、预后和治疗。包括来自加拿大蒙特利尔临床研究所(Institut de Recherches Cliniques de Montréal, IRCM)的研究人员Éric Racine博士在内的一个国际研究小组分析了临床医生如今正在面临着的临床、社会和伦理问题。他们的论文发表在2012年8月那期Lancet Neurology期刊上。Racine博士解释道，意识障碍病人在传统上被定义是没有意识，但是最近的临床研究发现揭示一些病人存在意识，但是被临床医生诊断为无意识。

如今，新的技术进步能够测量处于静息状态和独立于肌肉功能而对简单指令作出反应时的大脑功能，从而能够有助于建立更加准确的诊断。因此，诊断分类需要进行修正而且预后知识也得到改善。最近的治疗研究第一次证实治疗对病人反应性改善的影响。

Racine博士说，“阻止治疗或继续康复，或者将病人转移到长期护理机构的医学决策对病人家族而言比较困难，但是病人家族成员作出的最为困难的治疗决策之一就是病人是够继续维持生命的治疗或者还是停止治疗而只提供姑息治疗(palliative care)。”

媒体对意识障碍病人的报道越来越多，而且关于病人的信息也越来越为大众所知晓。诸如神经病学家、康复专家、家庭医生和护士之类的临床医生必须能够解决来自病人家庭成员对新诊断和治疗方法的更多需求。

本文编译自Disorders of consciousness: How should clinicians respond to new therapeutic interventions?

doi: 10.1016/S1474-4422(12)70154-0
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Disorders of consciousness: responding to requests for novel diagnostic and therapeutic interventions

Dr Ralf J Jox MD a , Prof James L Bernat MD b, Prof Steven Laureys MD c, Eric Racine PhD

Severe brain injury can leave patients with chronic disorders of consciousness. Because of impaired responsiveness, many of these patients have traditionally been regarded as unaware. However, findings from recent clinical studies herald a potential paradigm shift: functional imaging and neurophysiological studies have identified ways to assess awareness and have revealed astounding cases of awareness despite clinical unresponsiveness. Hence, diagnostic classifications have been rewritten, prognostic knowledge is improving, and therapeutic studies have regained momentum, showing for the first time some therapeutic effects on responsiveness. Clinicians must increasingly respond to requests by patients’ families and surrogate decision makers to use novel techniques for diagnosis, prognosis, and treatment, and in doing so several ethical and social issues need to be considered. Such requests provide an opportunity for clinicians to learn about patients’ values and preferences and to maintain clinical acumen for changes in patient status with the patients’ best interests in mind.