Introduction

A disorder of consciousness, or impaired consciousness, is a state where consciousness has been affected by damage to the brain.

Consciousness requires both wakefulness and awareness.

Wakefulness is the ability to open your eyes and have basic reflexes such as coughing, swallowing and sucking.

Awareness is associated with more complex thought processes and is more difficult to assess.Currently, the assessment of awareness relies on physical responses being detected during an examination.

The main disorders of consciousness are:

• coma
• vegetative state
• minimally conscious state

Coma

A coma is when a person shows no signs of being awake and no signs of being aware. A person in a coma lies with their eyes closed and doesn'trespond to their environment, voices or pain.

A coma usually lasts for less than two to four weeks, during which time a person may wake up or progress into a vegetative state or minimally conscious state.

They're also able to regulate their heartbeat and breathing without assistance.

However, a person in a vegetative state doesn't show any meaningful responses, such as following an object with their eyes or responding to voices. They also show no signs of experiencing emotions.

If a person is in a vegetative state for a long time, it may be considered to be:

• a continuing vegetative state when it's been longer than four weeks
• a permanent vegetative state whenit's beenmore than six months if caused by a non-traumatic brain injury, or more than 12 months if caused by a traumatic brain injury

If a person is diagnosed as being in a permanent vegetative state, recovery is extremely unlikely but not impossible.

Minimally conscious state

A person who shows clear but minimal or inconsistent awareness is classified as being in a minimally conscious state. They may have periods where they can communicate or respond to commands, such as moving a finger when asked.

A person may enter a minimally conscious state after being in a coma or vegetative state. In some cases a minimally conscious state is a stage on the route to recovery, but in others it's permanent.

As withvegetative state, a continuing minimally conscious state means it has lasted longer than four weeks. However, it's more difficult to diagnose a permanent minimally conscious state because it depends on things such as:

• the type of brain injury
• how severe the injury is
• how responsive the person is

In most cases, a minimally conscious state isn't usually considered to be permanent until it's lasted several years.

Why they happen

Disorders of consciousness can occur if the parts of the brain involved with consciousness are damaged. These types of brain injury can be divided into:

• traumatic brain injury the result of a Head injury, severe , such asan injurysustained during a car accident or a fall from a great height
• non-traumatic brain injury where the injury to the brain is caused by a health condition, such as a stroke
• progressive brain damage where the brain is gradually damaged over time; for example, because of Alzheimer's disease

Instead, supportive treatment is used to give the best chance of natural improvement. This can involve:

• providing nutrition through a feeding tube
• making surethe person is moved regularly so they don't develop pressure ulcers
• gently exercising their joints to prevent them becoming tight
• keeping their skin clean
• managing their bowel and bladder for example, using a tube known as a catheter to drain the bladder
• keeping their teeth and mouth clean
• offering opportunities for periods of meaningful activity such as listening to music or watching television, being shown pictures or hearing family members talking

Sensory stimulation

In some cases, a treatment called sensory stimulation may be used in an attempt to increase responsiveness. This involves stimulating the main senses, such as vision, hearing and smell.

It's usually carried out by a trained specialist, but family members are often encouraged to be involved.

Some examples of sensory stimulation include:

• visual showing photos of friends and family, or a favourite film
• hearing talking or playing a favourite song
• smell putting flowers in the room or spraying a favourite perfume
• touch holding their hand or stroking their skin with different fabrics

It's not entirely clear how effective sensory stimulation is, but it's sometimes considered worthwhile.

Recovery

It's impossible to predict the chances of someone in a state of impaired consciousness improving. It largely depends on:

• the type of brain injury
• how severe the injury is
• the person's age
• how long they've been inthe state for

Some people improve gradually, whereas others stay in a state of impaired consciousness for years. Many people never recover consciousness.

There are only isolated cases of people recovering consciousness after several years. The few people who do regain consciousness after this time often have severe disabilities caused by the damage to their brain.

Withdrawing nutritional support

If a person has been in a vegetative state for a minimum of 12 months, it may be recommended that nutritional support is withdrawn.

This is because:

• there's almost no chance of a recovery by this point
• prolonging life would have no benefit for the person concerned
• prolonging treatment could offer false hope and cause unnecessary emotional distress for the friends and family of the person concerned

The medical team will discuss the issue with family members, but the decision has to be referred to the courts in England, Wales and Northern Ireland before any further action can be taken. In Scotland a court ruling isn't required, but is often sought.

If the court agrees with the decision, a palliative care team will usually be involved in planning the withdrawal. Once nutritional support is eventually withdrawn, the person will die within a few days or weeks.