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Assessment of Covert Consciousness in the Intensive Care Unit

Clinical and Ethical Considerations

Edlow, Brian L. MD; Fins, Joseph J. MD, MACP, FRCP

The Journal of Head Trauma Rehabilitation: November/December 2018 - Volume 33 - Issue 6 - p 424–434
doi: 10.1097/HTR.0000000000000448
Special Feature

Objective: 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).

Methods: 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.

Results: 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.

Conclusions: 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.

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).

Corresponding Author: Brian L. Edlow, MD, Center for Neurotechnology and Neurorecovery, Massachusetts General Hospital, 175 Cambridge St, Ste 300, Boston, MA 02114 (

This work was supported by grants from the NIH National Institute of Neurological Disorders and Stroke (K23NS094538), Jerold B. Katz Foundation, and the James S. McDonnell Foundation.

The authors thank Kimberly Main Knoper for assistance with artwork in Figures 1 and 3.

The authors declare no conflicts of interest.

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