Single case reports on late recovery from chronic disorders of consciousness: A systematic review and ethical appraisal

Late recovery from the vegetative state/unresponsive wakefulness syndrome (VS/UWS) three months after nontraumatic brain injury and one year after traumatic brain injury is considered to be exceedingly rare. The VS/UWS is declared permanent after these time frames. Prognosis of recovery from the VS/UWS is central for decisions about life-sustaining treatment and hence of ethical relevance. Objectives: We aimed to describe single case reports of late recovery from permanent VS/UWS in scientific journals with a focus on the description of improvements and outcomes. Methods: We conducted a systematic review of single case descriptions searching PubMed and the Cases Database for synonyms of disorders of consciousness and the term “recovery”. Results: We screened 1406 records and identified 15 single case reports in 17 scientific journals from 1977 to 2012. Recovery was noticed between four and 33 months after brain injury of non-traumatic etiology, and between 15 months and six years after traumatic brain injury with outcomes ranging from minimally conscious state to almost full recovery (re-entering productive work). The reports were heterogeneous, and some of them lacked important information. Discussion: Single case reports on late recovery exist and call into question the justification for timeframes in established prognostic guidelines. We suggest a systematic approach to follow-up on single cases (e.g. a prospective case registry) to improve the evidence-base for prognosis. We also propose recommendations for an improved reporting and recommend further reflection on the role of case studies of recovery from disorders of consciousness in the discourse on end-of-life decision making.

Kuelmeyer K, Klinger C, Racine E, Jox, R. (2013). Single case reports on late recovery from chronic disorders of consciousness: A systematic review and ethical appraisal. Neuroethik / Neuroéthique / Neuroethics in Bioethica Forum, 4(6)