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J Head Trauma Rehabil. 2018 Nov/Dec;33(6):424-434. doi: 10.1097/HTR.0000000000000448.

Assessment of Covert Consciousness in the Intensive Care Unit: Clinical and Ethical Considerations.

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Department of Neurology, Center for Neurotechnology and Neurorecovery, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, and Athinoula A. Martinos Center for Biomedical Imaging, Massachusetts General Hospital, Charlestown (Dr Edlow); and Division of Medical Ethics and Consortium for the Advanced Study of Brain Injury, Weill Cornell Medical College, New York, and The Rockefeller University, New York, and the Solomon Center for Health Law and Policy, Yale Law School, New Haven, Connecticut (Dr Fins).



To propose a practical ethical framework for how task-based functional magnetic resonance imaging (fMRI) and electroencephalography (EEG) may be used in the intensive care unit (ICU) to identify covert consciousness in patients with acute severe traumatic brain injury (TBI).


We present 2 clinical scenarios in which investigational task-based fMRI and EEG were performed in critically ill patients with acute severe TBI who appeared unconscious on the bedside behavioral assessment. From these cases, we consider the clinical and ethical challenges that emerge and suggest how to reconcile them. We also provide recommendations regarding communication with families about ICU patients with covert consciousness.


Covert consciousness was detected acutely in a patient who died in the ICU due to withdrawal of life-sustaining therapy, whereas covert consciousness was not detected in a patient who subsequently recovered consciousness, communication, and functional independence. These cases raise ethical challenges about how assessment of covert consciousness in the ICU might inform treatment decisions, prognostication, and perceptions about the benefits and burdens of ongoing care.


Given that covert consciousness can be detected acutely in the ICU, we recommend that clinicians reconsider evaluative norms for ICU patients. As our clinical appreciation of covert consciousness evolves and its ethical import unfolds, we urge prognostic humility and transparency when clinicians communicate with families in the ICU about goals of care.

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