Education to Improve Understanding of Ethical and Communication Issues Around Disorders of Consciousness

Education to Improve Understanding of Ethical and Communication Issues Around Disorders of Consciousness | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Education to Improve Understanding of Ethical and Communication Issues Around Disorders of Consciousness Grant Barrett, Abram Brummett This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-7576977/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Background Disorders of consciousness are a classification of neurological syndromes that involve the disruption of wakefulness and/or awareness. Coma, minimally conscious state, and persistent vegetative state are the main categories within the spectrum of disorders of consciousness, each with distinct characteristics and associated ethical dilemmas. We investigated whether administering an educational intervention to medical residents, fellows, and students would improve the understanding of and confidence in approaching the diagnostic, communicative, and ethical complexities related to disorders of consciousness. Methods A 1-hour educational session covering ethical and communication challenges related to medical decision making for patients with disorders of consciousness was administered to residents, fellows and students at Corewell Health William Beaumont University Hospital. Participants completed a questionnaire containing a Likert scale before and after the intervention assessing their confidence in approaching diagnosis, treating, ethical challenges, and communication practices between both patients and surrogate decision makers for patients with various disorders of consciousness. Change in confidence was analyzed using Shapiro-Wilk tests to determine skew and Wilcoxon signed-rank test to compare pre and post intervention scores. Results A total of 23 trainees participated from July to December 2024. After the educational training session, trainees were more confident (p < .01) .describing standard kinds of disorders of consciousness and their behavioral differences, understanding the diagnostic error rate, challenges, and fMRI studies detecting covert awareness, understanding the “window of opportunity” and the challenge of clinical nihilism among those recovering from TBI, and in their ability to communicate appropriately with surrogates about brain injury and with patients in a minimally conscious state. Conclusions Medical decision making for patients with disorders of consciousness is fraught with ethical and communication challenges. These findings support the use and delivery of 1-hour targeted educational interventions to better prepare medical trainees for future encounters with families and patients with a disorder of consciousness. Trial Registration Oakland University IRB-FY2025-4 – Category 2 Exempt Decision Disorder of conciousness Neuroethics Surrogate burden Medical education Coma Persistent vegetative state Minimally conscious state Ethics of uncertainty Introduction Disorders of consciousness (DoCs) are a classification of neurological syndromes that involve the disruption of wakefulness and/or awareness. Challenges in the management of DoCs include misdiagnosis and clinical nihilism (i.e., an overly pessimistic prognostication 1 ), amid evolving research (e.g., the adaptive recovery index 2 , deep brain stimulation 3 ) that pose profound challenges for communication and medical decision making. The evolving taxonomy of DoCs includes coma, persistent vegetative state (PVS) and minimally conscious state (MCS). Comatose patients do not experience sleep-wake cycles and are unaware of their environment. In terms of the prognosis of coma, it is known that coma is self-limited lasting up to 10 to 14 days, after which comatose patients typically either recover and awaken, transition into a MCS or PVS state, or die. 4 , 5 PVS patients are in a state of wakefulness and do not have awareness of themselves or their environment. In PVS patients, the ascending reticular activating system is intact leading to wakefulness; however, patients lack awareness due to cerebral hemisphere damage. PVS patients therefore exhibit only reflex behaviors. MCS patients are differentiated from PVS patients by the partial preservation of conscious awareness, such as the ability to localize sound, sustained visual fixation, and contingent vocalization, smiling, or crying. Patients may evolve to MCS from a vegetative state or coma, and this condition may be transient or permanent. 4 , 5 Duration of coma is typically linked to prognosis characteristics and recovery chance. This transition from coma into PVS and MCS leads to questions regarding medical interventions and ethical considerations for patients and their families, as patients who are in PVS or MCS can remain in these states for many years without noticeable changes in wakefulness and awareness. 4 Consequently, disorders of consciousness often lead to uncertainty surrounding prognosis, treatment options, and the potential for recovery. Physicians are faced with the challenging task of balancing hope and support with the responsibility to convey accurate information and facilitate informed decision-making. Likewise, surrogates for these patients are often placed in situations where prognosis may change, or the patient may have varying levels of decision-making capacity. It has been reported that there is only a 68% accuracy rate of surrogates correctly predicting a patient's treatment preferences, and this rate did not improve among surrogates who had previously discussed such preferences with the patient. 6 , 7 Regarding knowledge of the patient’s condition, one study has shown that 90% of caregivers of patients in PVS thought of the patient as conscious. 3 This discrepancy in surrogate and family understanding of the patient’s true level of consciousness and ability to recover showcases the importance of clear, concise communication of a complex topic such as DoC’s. Methods Educational Intervention The sample was drawn from residents and fellows at Corewell Health William Beaumont University Hospital, who participated in the educational intervention. A 1-hour session included structured content across five key areas: the evolving taxonomy of disorders of consciousness, misdiagnosis, prognosis, and communication challenges with both surrogates and patients (when in a responsive MCS). Each section included time for small group reflection and discussion. All content administered was reviewed by the chair of neurology and delivered by a staff clinical ethicist. An overarching theme of the session was the challenge of uncertainty that complicates decision making for patients with DoCs. 8 Survey Design & Assessment We developed a 5-item survey focused on assessing participant’s confidence across 6 learning objectives (Appendix A): Describe standard kinds of disorders of consciousness and the behavioral differences between them. Understanding of the diagnostic error rate, challenges, and fMRI studies detecting covert awareness in some patients believed to be in a vegetative state. Understanding of the “window of opportunity” and how clinical nihilism has been recently challenged by data on recovery and treatment of patients with TBI. Communicate appropriately with surrogates about severe brain injury. Communicate appropriately with patients in a minimally conscious state. This educational intervention was developed for medical trainees who may not have had any previous experience with treating or diagnosing disorders of consciousness. Given this, the purpose of the questionnaire was to assess the participant’s knowledge and confidence of the listed objectives before and after the educational session. The survey was distributed before and after the educational intervention. There was no control group for this study. All items were scored on a 5-point Likert scale (1 = strongly disagree, 5 = strongly agree. Two optional questions allowed trainees to give feedback to the facilitators. Shapiro-Wilk tests on the distribution of pre- and post-session responses for each item indicated significant skewness (p < .05 for each item). Therefore, a Wilcoxon signed-rank test was used to compare pre- and post-intervention scores. The Mann-Whitney U test was used to compare scores between nominal variables. A Bonferroni correction was applied to account for multiple comparisons. Statistical significance was assessed at α = .05. All statistical analysis in this paper utilized STATA version 18.5. Results There were five didactic educational sessions with a total of 23 medical trainees that occurred between July 2024 to December 2024. All trainees who participated in the sessions took the survey. Group sizes ranged from three to seven with a median number of four trainees present for each session. The cohorts represented a wide range of both medical specialty and years of training: pulmonary and critical care fellowship, internal medicine residency, emergency medicine residency, anesthesiology residency, transitional year, and a fourth-year medical student (Table 1 ). The demographics of the study cohort was 22% female (n = 5) and 78% male (n = 18). 47% of the participants were enrolled in an internal medicine residency (n = 11), 26% were pulmonary and critical care fellows (n = 6), and 13% were emergency medicine residents (n = 3). 35% of trainees were PGY-1 residents (n = 8), 22% were PGY-2 residents (n = 5), while 26% of trainees were first year (F1/PGY-4) (n = 6) fellows (Table 1 ). After the educational session, trainees were more confident in their abilities to describe, understand, and communicate the various ethical, diagnostic, and treatment aspects of caring for patients and families affected by DoC’s. Results from the relevant questions in the survey assessing the learning objectives from the intervention showcased a universal increase of this understanding. Trainees showed an increased confidence in their ability to describe the standard kinds of disorders of consciousness and the behavioral differences between them, as well as an improved confidence in the understanding of the diagnostic error rate, challenges, and fMRI studies detecting covert awareness in some patients believed to be in a vegetative state. After the intervention, trainees were also significantly more confident in their understanding of the “window of opportunity” and how clinical nihilism has been recently challenged by data on recovery and treatment of patients with TBI. Trainees showed an increased confidence in their ability to communicate appropriately with both surrogates about brain injury, as well as with patients in minimally conscious states (Table 2 ). Participants in this intervention were encouraged to include qualitative, open-ended responses at the end of the survey to provide feedback on the training session. These responses included appreciating a small group, interactive environment during the lecture that emphasized open, transparent communication without judgement. Table 1 Participant Demographics (N = 23) Demographics Number Percentage % Gender Female 5 22 Male 18 78 Program Internal Medicine Residency 11 48 Emergency Medicine Residency 3 13 Medical Student 1 4 Pulmonary & Critical Care Fellowship 6 26 Anesthesiology Residency 1 4 Transitional Year 1 4 Stage of training M4 1 4 PGY 1 8 35 PGY 2 5 22 PGY 3 2 9 F1 (PGY-4) 6 26 Table 2 Participant Survey Responses Pre- Versus Post Intervention Participation Survey Item Assessing Confidence in Ability to Pre Intervention Mdn (IQR) a Post Intervention Mdn (IQR) a p-value b Describe standard kinds of DoC’s and their behavioral differences 3 (3–4) 4 (4–5) 0.002 Understand diagnostic error rate, challenges, and fMRI studies detecting covert awareness in PVS patients 3(2–4) 4 (4–5) 0.0015 Understand window of opportunity and clinical nihilism challenged by data on recovery and treatment of TBI patients 3 (2–4) 5 (4–5) 0.0000 Communicate appropriately with surrogates about severe brain injury 4 (3–4) 4 (4–5) 0.0005 Communicate appropriately with MCS patients 3 (4–5) 4 (4–5) 0.0000 a Survey items were scored on a 5-point Likert scale (1 = strongly disagree, 5 = strongly agree). b Calculated using a Wilcoxon signed rank test; p values include Bonferroni adjustments for multiple comparisons Discussion The results of this 1-hour session indicate a successful educational intervention on the challenges of caring for patients with disorders of consciousness. In each of the five key portions of the session, various points for discussion were first raised before providing best practices or consensus positions. This gave a chance for trainees to experience the complexity of these issues through lively discourse before providing guidance for future practice. Although this is a primarily neurological and critical care-based topic, the trainees were part of a diverse group of specialties and interests. This allowed for meaningful discussion among the group at each session, leading to conversations that highlighted and uncovered the various complexities of DoC’s such as the “window of opportunity” and the use of fMRI to determine wakefulness in minimally conscious patients and subsequent discussions about empathetic, realistic communication with a surrogate decision maker. 9 , 10 Our results suggest that the administration of a 1-hour DoC specific didactic intervention that covers diagnosis, treatment, ethics, and communication would subsequently allow participants to more effectively engage in better medical, ethical, and interpersonal practices. We can infer that in order to better treat patients with DoC’s and communicate with them and their designated surrogates, a foundational understanding of the taxonomy and ethics of DoC’s and the advancing imaging techniques such as fMRI utilized in such cases of PVS or MCS was required. While a 1-hour session has limitations, the five key sections of this intervention were able to cover the most salient information regarding DoCs, and post survey results indicate a higher level of understanding of these topics after delivery. This relatively short training session, although non-longitudinal, provided medical trainees with valuable information that emphasized communication in an effective manner which can allow them to gain specific understanding of a complex medical and ethical topic during their medical education. This 1-hour session, delivered once a month to a wide range of participants at different stages of their medical training, allowed for a nondisruptive, integrated learning opportunity that showcases how implementing a small group, focused didactic session can lead to substantial, significant improvements in the understanding and confidence in treating conditions that may require complicated management and ethical considerations. Of note, the survey was developed by our research team and did not represent a validated tool. Development of a validated tool would be a useful addition to the future study of DoC simulations for standardization purposes. Abbreviations DoC = Disorder of Consciousness; PVS = Persistent Vegetative State; MCS = Minimally Conscious State Declarations Ethics approval and Consent to Participate This study was approved by the Institutional Review Board of Oakland informed consent in the first page of the survey instrument prior to Consent For Publication Not applicable. Competing interests The authors declare that they have no competing interests. Study Funding No targeted funding reported. The authors report no disclosures relevant to the manuscript. Appendices A – Outline for DoC.pdf B – Brain Injury Presentation.pptx C – Qualtrics Survey.pdf Author Contribution A.B designed and led the educational intervention and provided edits and changes to the manuscript.G.B wrote the rough and final drafts of the manuscript and prepared all figures and tables.All authored reviewed the manuscript. Acknowledgements Not applicable. Data Availability Anonymized datasets used and analyzed during the current study, not published within this article, will be made available by request from any qualified investigator. References Caplan AL, Joseph J. Fins' Rights Come to Mind: Brain Injury, Ethics and the Struggle for Consciousness. Cerebrum. 2017;2017:cer–09. Published 2017 Jul 1. Duclos C, Maschke C, Mahdid Y, et al. Brain Responses to Propofol in Advance of Recovery from Coma and Disorders of Consciousness: A Preliminary Study. Am J Respir Crit Care Med. 2022;205(2):171–82. 10.1164/rccm.202105-1223OC . Schiff ND, Giacino JT, Fins JJ. Deep Brain Stimulation, Neuroethics, and the Minimally Conscious State: Moving Beyond Proof of Principle. Arch Neurol. 2009;66(6):697–702. 10.1001/archneurol.2009.79 . Laureys S, Owen AM, Schiff ND. Brain function in coma, vegetative state, and related disorders. Lancet Neurol. 2004;3(9):537–46. 10.1016/s1474-4422(04)00852-x . Giacino JT, Ashwal S, Childs N, et al. The minimally conscious state: definition and diagnostic criteria. Neurology. 2002;58(3):349–53. 10.1212/wnl.58.3.349 . Shalowitz DI, Garrett-Mayer E, Wendler D. The accuracy of surrogate decision makers: a systematic review. Arch Intern Med. 2006;166(5):493–7. 10.1001/archinte.166.5.493 . Tresch DD, Sims FH, Duthie EH Jr, Goldstein MD. Patients in a persistent vegetative state attitudes and reactions of family members. J Am Geriatr Soc. 1991;39(1):17–21. 10.1111/j.1532-5415.1991.tb05900.x . Johnson L, Syd M, Syd L, Johnson M. 'The Ethics of Uncertainty', The Ethics of Uncertainty: Entangled Ethical and Epistemic Risks in Disorders of Consciousness (New York, 2021; online edn, Oxford Academic, 1 Oct. 2021). https://doi.org/10.1093/med/9780190943646.003.0006 Kitzinger J, Kitzinger C. The 'window of opportunity' for death after severe brain injury: family experiences. Sociol Health Illn. 2013;35(7):1095–112. 10.1111/1467-9566.12020 . Edlow BL, Claassen J, Schiff ND, et al. Recovery from disorders of consciousness: mechanisms, prognosis and emerging therapies. Nat Rev Neurol. 2021;17:135–56. https://doi.org/10.1038/s41582-020-00428-x . Additional Declarations No competing interests reported. Supplementary Files OutlineforDoC.pdf BrainInjuryPresentation.pptx QualtricsSurvey.pdf Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. 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Challenges in the management of DoCs include misdiagnosis and clinical nihilism (i.e., an overly pessimistic prognostication\u003csup\u003e\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e\u003c/sup\u003e), amid evolving research (e.g., the adaptive recovery index\u003csup\u003e\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e\u003c/sup\u003e, deep brain stimulation\u003csup\u003e\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e\u003c/sup\u003e) that pose profound challenges for communication and medical decision making.\u003c/p\u003e\u003cp\u003eThe evolving taxonomy of DoCs includes coma, persistent vegetative state (PVS) and minimally conscious state (MCS). Comatose patients do not experience sleep-wake cycles and are unaware of their environment. In terms of the prognosis of coma, it is known that coma is self-limited lasting up to 10 to 14 days, after which comatose patients typically either recover and awaken, transition into a MCS or PVS state, or die.\u003csup\u003e\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e,\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e\u003c/sup\u003e PVS patients are in a state of wakefulness and do not have awareness of themselves or their environment. In PVS patients, the ascending reticular activating system is intact leading to wakefulness; however, patients lack awareness due to cerebral hemisphere damage. PVS patients therefore exhibit only reflex behaviors. MCS patients\u003c/p\u003e\u003cp\u003eare differentiated from PVS patients by the partial preservation of conscious awareness, such as the ability to localize sound, sustained visual fixation, and contingent vocalization, smiling, or crying. Patients may evolve to MCS from a vegetative state or coma, and this condition may be transient or permanent.\u003csup\u003e\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e,\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e\u003cp\u003eDuration of coma is typically linked to prognosis characteristics and recovery chance. This transition from coma into PVS and MCS leads to questions regarding medical interventions and ethical considerations for patients and their families, as patients who are in PVS or MCS can remain in these states for many years without noticeable changes in wakefulness and awareness.\u003csup\u003e\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e\u003c/sup\u003e Consequently, disorders of consciousness often lead to uncertainty surrounding prognosis, treatment options, and the potential for recovery. Physicians are faced with the challenging task of balancing hope and support with the responsibility to convey accurate information and facilitate informed decision-making.\u003c/p\u003e\u003cp\u003eLikewise, surrogates for these patients are often placed in situations where prognosis may change, or the patient may have varying levels of decision-making capacity. It has been reported that there is only a 68% accuracy rate of surrogates correctly predicting a patient's treatment preferences, and this rate did not improve among surrogates who had previously discussed such preferences with the patient.\u003csup\u003e\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e,\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e\u003c/sup\u003e Regarding knowledge of the patient\u0026rsquo;s condition, one study has shown that 90% of caregivers of patients in PVS thought of the patient as conscious.\u003csup\u003e\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e\u003c/sup\u003e This discrepancy in surrogate and family understanding of the patient\u0026rsquo;s true level of consciousness and ability to recover showcases the importance of clear, concise communication of a complex topic such as DoC\u0026rsquo;s.\u003c/p\u003e"},{"header":"Methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e\u003ch2\u003eEducational Intervention\u003c/h2\u003e\u003cp\u003eThe sample was drawn from residents and fellows at Corewell Health William Beaumont University Hospital, who participated in the educational intervention. A 1-hour session included structured content across five key areas: the evolving taxonomy of disorders of consciousness, misdiagnosis, prognosis, and communication challenges with both surrogates and patients (when in a responsive MCS). Each section included time for small group reflection and discussion. All content administered was reviewed by the chair of neurology and delivered by a staff clinical ethicist. An overarching theme of the session was the challenge of uncertainty that complicates decision making for patients with DoCs.\u003csup\u003e\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e\u003c/div\u003e\n\u003ch3\u003eSurvey Design \u0026 Assessment\u003c/h3\u003e\n\u003cp\u003eWe developed a 5-item survey focused on assessing participant\u0026rsquo;s confidence across 6 learning objectives (Appendix A):\u003c/p\u003e\u003cp\u003e\u003col\u003e\u003cspan\u003e\u003cli\u003e\u003cp\u003eDescribe standard kinds of disorders of consciousness and the behavioral differences between them.\u003c/p\u003e\u003c/li\u003e\u003c/span\u003e\u003cspan\u003e\u003cli\u003e\u003cp\u003eUnderstanding of the diagnostic error rate, challenges, and fMRI studies detecting covert awareness in some patients believed to be in a vegetative state.\u003c/p\u003e\u003c/li\u003e\u003c/span\u003e\u003cspan\u003e\u003cli\u003e\u003cp\u003eUnderstanding of the \u0026ldquo;window of opportunity\u0026rdquo; and how clinical nihilism has been recently challenged by data on recovery and treatment of patients with TBI.\u003c/p\u003e\u003c/li\u003e\u003c/span\u003e\u003cspan\u003e\u003cli\u003e\u003cp\u003eCommunicate appropriately with surrogates about severe brain injury.\u003c/p\u003e\u003c/li\u003e\u003c/span\u003e\u003cspan\u003e\u003cli\u003e\u003cp\u003eCommunicate appropriately with patients in a minimally conscious state.\u003c/p\u003e\u003c/li\u003e\u003c/span\u003e\u003c/ol\u003e\u003c/p\u003e\u003cp\u003eThis educational intervention was developed for medical trainees who may not have had any previous experience with treating or diagnosing disorders of consciousness. Given this, the purpose of the questionnaire was to assess the participant\u0026rsquo;s knowledge and confidence of the listed objectives before and after the educational session.\u003c/p\u003e\u003cp\u003eThe survey was distributed before and after the educational intervention. There was no control group for this study. All items were scored on a 5-point Likert scale (1\u0026thinsp;=\u0026thinsp;strongly disagree, 5\u0026thinsp;=\u0026thinsp;strongly agree. Two optional questions allowed trainees to give feedback to the facilitators. Shapiro-Wilk tests on the distribution of pre- and post-session responses for each item indicated significant skewness (p\u0026thinsp;\u0026lt;\u0026thinsp;.05 for each item). Therefore, a Wilcoxon signed-rank test was used to compare pre- and post-intervention scores. The Mann-Whitney U test was used to compare scores between nominal variables. A Bonferroni correction was applied to account for multiple comparisons. Statistical significance was assessed at α\u0026thinsp;=\u0026thinsp;.05. All statistical analysis in this paper utilized STATA version 18.5.\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003eThere were five didactic educational sessions with a total of 23 medical trainees that occurred between July 2024 to December 2024. All trainees who participated in the sessions took the survey. Group sizes ranged from three to seven with a median number of four trainees present for each session. The cohorts represented a wide range of both medical specialty and years of training: pulmonary and critical care fellowship, internal medicine residency, emergency medicine residency, anesthesiology residency, transitional year, and a fourth-year medical student (Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eThe demographics of the study cohort was 22% female (n\u0026thinsp;=\u0026thinsp;5) and 78% male (n\u0026thinsp;=\u0026thinsp;18). 47% of the participants were enrolled in an internal medicine residency (n\u0026thinsp;=\u0026thinsp;11), 26% were pulmonary and critical care fellows (n\u0026thinsp;=\u0026thinsp;6), and 13% were emergency medicine residents (n\u0026thinsp;=\u0026thinsp;3). 35% of trainees were PGY-1 residents (n\u0026thinsp;=\u0026thinsp;8), 22% were PGY-2 residents (n\u0026thinsp;=\u0026thinsp;5), while 26% of trainees were first year (F1/PGY-4) (n\u0026thinsp;=\u0026thinsp;6) fellows (Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e).\u003c/p\u003e\u003cp\u003e After the educational session, trainees were more confident in their abilities to describe, understand, and communicate the various ethical, diagnostic, and treatment aspects of caring for patients and families affected by DoC\u0026rsquo;s. Results from the relevant questions in the survey assessing the learning objectives from the intervention showcased a universal increase of this understanding.\u003c/p\u003e\u003cp\u003eTrainees showed an increased confidence in their ability to describe the standard kinds of disorders of consciousness and the behavioral differences between them, as well as an improved confidence in the understanding of the diagnostic error rate, challenges, and fMRI studies detecting covert awareness in some patients believed to be in a vegetative state. After the intervention, trainees were also significantly more confident in their understanding of the \u0026ldquo;window of opportunity\u0026rdquo; and how clinical nihilism has been recently challenged by data on recovery and treatment of patients with TBI. Trainees showed an increased confidence in their ability to communicate appropriately with both surrogates about brain injury, as well as with patients in minimally conscious states (Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eParticipants in this intervention were encouraged to include qualitative, open-ended responses at the end of the survey to provide feedback on the training session. These responses included appreciating a small group, interactive environment during the lecture that emphasized open, transparent communication without judgement.\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eParticipant Demographics (N\u0026thinsp;=\u0026thinsp;23)\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"3\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eDemographics\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eNumber\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003ePercentage %\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003ctr\u003e\u003cth align=\"left\" colspan=\"3\" nameend=\"c3\" namest=\"c1\"\u003e\u003cp\u003eGender\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eFemale\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e5\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e22\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eMale\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e18\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e78\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"3\" nameend=\"c3\" namest=\"c1\"\u003e\u003cp\u003e\u003cb\u003eProgram\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eInternal Medicine Residency\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e11\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e48\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eEmergency Medicine Residency\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e3\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e13\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eMedical Student\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e4\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003ePulmonary \u0026amp; Critical Care Fellowship\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e6\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e26\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eAnesthesiology Residency\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e4\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eTransitional Year\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e4\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"3\" nameend=\"c3\" namest=\"c1\"\u003e\u003cp\u003e\u003cb\u003eStage of training\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eM4\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e4\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003ePGY 1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e8\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e35\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003ePGY 2\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e5\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e22\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003ePGY 3\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e2\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e9\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eF1 (PGY-4)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e6\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e26\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eParticipant Survey Responses Pre- Versus Post Intervention Participation\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"4\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eSurvey Item Assessing Confidence in Ability to\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003ePre Intervention\u003c/p\u003e\u003cp\u003eMdn (IQR)\u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003ePost Intervention\u003c/p\u003e\u003cp\u003eMdn (IQR)\u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003e\u003cem\u003ep-value\u003c/em\u003e\u003csup\u003eb\u003c/sup\u003e\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eDescribe standard kinds of DoC\u0026rsquo;s and their behavioral differences\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e3 (3\u0026ndash;4)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e4 (4\u0026ndash;5)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.002\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eUnderstand diagnostic error rate, challenges, and fMRI studies detecting covert awareness in PVS patients\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e3(2\u0026ndash;4)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e4 (4\u0026ndash;5)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.0015\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eUnderstand window of opportunity and clinical nihilism challenged by data on recovery and treatment of TBI patients\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e3 (2\u0026ndash;4)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e5 (4\u0026ndash;5)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.0000\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eCommunicate appropriately with surrogates about severe brain injury\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e4 (3\u0026ndash;4)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e4 (4\u0026ndash;5)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.0005\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eCommunicate appropriately with MCS patients\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e3 (4\u0026ndash;5)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e4 (4\u0026ndash;5)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.0000\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"4\" nameend=\"c4\" namest=\"c1\"\u003e\u003cp\u003e\u003csup\u003e\u003cem\u003ea\u003c/em\u003e\u003c/sup\u003e\u003cem\u003eSurvey items were scored on a 5-point Likert scale (1\u0026thinsp;=\u0026thinsp;strongly disagree, 5\u0026thinsp;=\u0026thinsp;strongly agree).\u003c/em\u003e\u003c/p\u003e\u003cp\u003e\u003csup\u003e\u003cem\u003eb\u003c/em\u003e\u003c/sup\u003e\u003cem\u003eCalculated using a Wilcoxon signed rank test; p values include Bonferroni adjustments for multiple comparisons\u003c/em\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eThe results of this 1-hour session indicate a successful educational intervention on the challenges of caring for patients with disorders of consciousness. In each of the five key portions of the session, various points for discussion were first raised\u003c/p\u003e\u003cp\u003ebefore providing best practices or consensus positions. This gave a chance for trainees to experience the complexity of these issues through lively discourse before providing guidance for future practice.\u003c/p\u003e\u003cp\u003eAlthough this is a primarily neurological and critical care-based topic, the trainees were part of a diverse group of specialties and interests. This allowed for meaningful discussion among the group at each session, leading to conversations that highlighted and uncovered the various complexities of DoC\u0026rsquo;s such as the \u0026ldquo;window of opportunity\u0026rdquo; and the use of fMRI to determine wakefulness in minimally conscious patients and subsequent discussions about empathetic, realistic communication with a surrogate decision maker.\u003csup\u003e\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e,\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e\u003cp\u003eOur results suggest that the administration of a 1-hour DoC specific didactic intervention that covers diagnosis, treatment, ethics, and communication would subsequently allow participants to more effectively engage in better medical, ethical, and interpersonal practices. We can infer that in order to better treat patients with DoC\u0026rsquo;s and communicate with them and their designated surrogates, a foundational understanding of the taxonomy and ethics of DoC\u0026rsquo;s and the advancing imaging techniques such as fMRI utilized in such cases of PVS or MCS was required.\u003c/p\u003e\u003cp\u003eWhile a 1-hour session has limitations, the five key sections of this intervention were able to cover the most salient information regarding DoCs, and post survey results indicate a higher level of understanding of these topics after delivery. This relatively short training session, although non-longitudinal, provided medical trainees with valuable information that emphasized communication in an effective manner which can allow them to gain specific understanding of a complex medical and ethical topic during their medical education.\u003c/p\u003e\u003cp\u003eThis 1-hour session, delivered once a month to a wide range of participants at different stages of their medical training, allowed for a nondisruptive, integrated learning opportunity that showcases how implementing a small group, focused didactic session can lead to substantial, significant improvements in the understanding and confidence in treating conditions that may require complicated management and ethical considerations.\u003c/p\u003e\u003cp\u003eOf note, the survey was developed by our research team and did not represent a validated tool. Development of a validated tool would be a useful addition to the future study of DoC simulations for standardization purposes.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cp\u003e\u003cstrong\u003eDoC\u0026nbsp;\u003c/strong\u003e= Disorder of Consciousness; \u003cstrong\u003ePVS\u003c/strong\u003e = Persistent Vegetative State; \u003cstrong\u003eMCS\u003c/strong\u003e = Minimally Conscious State\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics approval and Consent to Participate\u003c/strong\u003e\u003cp\u003eThis study was approved by the Institutional Review Board of Oakland\u003c/p\u003e\u003c/p\u003e\u003cp\u003e\u003ch2\u003einformed consent\u003c/h2\u003e\u003cp\u003ein the first page of the survey instrument prior to\u003c/p\u003e\u003c/p\u003e\u003cp\u003e\u003ch2\u003eConsent For Publication\u003c/h2\u003e\u003cp\u003eNot applicable.\u003c/p\u003e\u003c/p\u003e\u003cp\u003e\u003ch2\u003eCompeting interests\u003c/h2\u003e\u003cp\u003eThe authors declare that they have no competing interests.\u003c/p\u003e\u003c/p\u003e\u003cp\u003e\u003ch2\u003eStudy Funding\u003c/h2\u003e\u003cp\u003eNo targeted funding reported. The authors report no disclosures relevant to the manuscript.\u003c/p\u003e\u003c/p\u003e\u003cp\u003e\u003ch2\u003eAppendices\u003c/h2\u003e\u003cp\u003eA \u0026ndash; Outline for DoC.pdf\u003c/p\u003e\u003cp\u003eB \u0026ndash; Brain Injury Presentation.pptx\u003c/p\u003e\u003cp\u003eC \u0026ndash; Qualtrics Survey.pdf\u003c/p\u003e\u003c/p\u003e\u003ch2\u003eAuthor Contribution\u003c/h2\u003e\u003cp\u003eA.B designed and led the educational intervention and provided edits and changes to the manuscript.G.B wrote the rough and final drafts of the manuscript and prepared all figures and tables.All authored reviewed the manuscript.\u003c/p\u003e\u003ch2\u003eAcknowledgements\u003c/h2\u003e\u003cp\u003eNot applicable.\u003c/p\u003e\u003ch2\u003eData Availability\u003c/h2\u003e\u003cp\u003eAnonymized datasets used and analyzed during the current study, not published within this article, will be made available by request from any qualified investigator.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eCaplan AL, Joseph J. 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The 'window of opportunity' for death after severe brain injury: family experiences. Sociol Health Illn. 2013;35(7):1095\u0026ndash;112. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1111/1467-9566.12020\u003c/span\u003e\u003cspan address=\"10.1111/1467-9566.12020\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eEdlow BL, Claassen J, Schiff ND, et al. Recovery from disorders of consciousness: mechanisms, prognosis and emerging therapies. Nat Rev Neurol. 2021;17:135\u0026ndash;56. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1038/s41582-020-00428-x\u003c/span\u003e\u003cspan address=\"10.1038/s41582-020-00428-x\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Disorder of conciousness, Neuroethics, Surrogate burden, Medical education, Coma, Persistent vegetative state, Minimally conscious state, Ethics of uncertainty","lastPublishedDoi":"10.21203/rs.3.rs-7576977/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-7576977/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e\u003cp\u003eDisorders of consciousness are a classification of neurological syndromes that involve the disruption of wakefulness and/or awareness. Coma, minimally conscious state, and persistent vegetative state are the main categories within the spectrum of disorders of consciousness, each with distinct characteristics and associated ethical dilemmas. We investigated whether administering an educational intervention to medical residents, fellows, and students would improve the understanding of and confidence in approaching the diagnostic, communicative, and ethical complexities related to disorders of consciousness.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e\u003cp\u003eA 1-hour educational session covering ethical and communication challenges related to medical decision making for patients with disorders of consciousness was administered to residents, fellows and students at Corewell Health William Beaumont University Hospital. Participants completed a questionnaire containing a Likert scale before and after the intervention assessing their confidence in approaching diagnosis, treating, ethical challenges, and communication practices between both patients and surrogate decision makers for patients with various disorders of consciousness. Change in confidence was analyzed using Shapiro-Wilk tests to determine skew and Wilcoxon signed-rank test to compare pre and post intervention scores.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e\u003cp\u003eA total of 23 trainees participated from July to December 2024. After the educational training session, trainees were more confident (p\u0026thinsp;\u0026lt;\u0026thinsp;.01) .describing standard kinds of disorders of consciousness and their behavioral differences, understanding the diagnostic error rate, challenges, and fMRI studies detecting covert awareness, understanding the \u0026ldquo;window of opportunity\u0026rdquo; and the challenge of clinical nihilism among those recovering from TBI, and in their ability to communicate appropriately with surrogates about brain injury and with patients in a minimally conscious state.\u003c/p\u003e\u003ch2\u003eConclusions\u003c/h2\u003e\u003cp\u003eMedical decision making for patients with disorders of consciousness is fraught with ethical and communication challenges. These findings support the use and delivery of 1-hour targeted educational interventions to better prepare medical trainees for future encounters with families and patients with a disorder of consciousness.\u003c/p\u003e\u003ch2\u003eTrial Registration\u003c/h2\u003e\u003cp\u003eOakland University IRB-FY2025-4 \u0026ndash; Category 2 Exempt Decision\u003c/p\u003e","manuscriptTitle":"Education to Improve Understanding of Ethical and Communication Issues Around Disorders of Consciousness","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-10-07 20:27:42","doi":"10.21203/rs.3.rs-7576977/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"66d8883e-b015-407e-bd93-f60cafd316c5","owner":[],"postedDate":"October 7th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2026-01-28T06:42:14+00:00","versionOfRecord":[],"versionCreatedAt":"2025-10-07 20:27:42","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-7576977","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-7576977","identity":"rs-7576977","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}