Advancing the Care of Patients with Disorders of Consciousness

The brain is one of the most complex organs in the body, and damage to it can cause a wide range of impairments called disorders of consciousness (DOC). In this session at the 2020 CLM Workers’ Compensation and Retail, Restaurant and Hospitality Conference, a panel discussed the three main disorders of consciousness and, when an injured worker suffers such an injury, how workers’ compensation should respond.

Speakers included:

• Michael Choo, Chief Medical Officer, Paradigm
• Robert Doherty, Partner, Evans & Dixon, L.L.C.
• Nancy Schulz, Director – Managed Care, Acuity Insurance

Defining and Diagnosing Disorders of Consciousness

It is crucial to understand the three main disorders of consciousness because their distinctions are clinically significant.

1. Coma state: Unconsciousness characterized by the complete loss of spontaneous or stimulus-induced arousal. It is a self-limited state (lasting 4-6 weeks), followed by evolution to either the vegetative state or minimally conscious state.
2. Vegetative state (VS): Unconsciousness with preserved capacity for spontaneous arousal, where patients have periods of wakefulness, like eye openings, yet remain unconscious. For this reason, it can be thought of as a state of “unarousable unconsciousness.” Unlike a coma, this state can be a chronic condition.
3. Minimally conscious state (MCS): Severely altered consciousness in which minimal, but definite, behavioral evidence of self and/or environmental awareness is demonstrated, although the behaviors can be subtle and inconsistent. This state can also be a chronic condition.

Disorders of consciousness are fluid, which makes it challenging to directly observe and assess the impairments. Studies have found high rates of diagnostic error in diagnosis (especially determining between VS and MCS). Misdiagnosis can have significant, and even devastating, consequences.

Because patients with DOC have severe medical and neurological complications that require management by clinicians with expertise in severe brain injuries, admission to specialized DOC programs are now recommended as the standard of care. Specific treatments include rehabilitation interventions, including sensory stimulation, mobilization and interpersonal interaction. Other treatments include energy modalities and pharmacological agents, including neuro stimulants and GABA agonists.

Legality and Workers’ Compensation Programs

Legality often revolves around recognition that patients with the capability to make the decision have a right to refuse therapy. If they are unable to do that, a surrogate can exercise this right for them. To ensure the most medically ethical decision can be made within the limits of the law, it is important for everyone involved to have a clear understanding of state law and relevant case studies for DOC patients.

When a patient is diagnosed with DOC due to a traumatic brain injury, workers’ compensation comes into play. Given the paramount importance of accurate diagnosis and effective treatments to the best functional outcomes for patients with a prolonged DOC, workers’ compensation practices should support admission to specialized treatment.

To ensure proper decisions are made from a workers’ compensation standpoint, claims professionals and other stakeholders should be aware of the importance of having the injured worker with DOC conditions properly evaluated and treated by high-quality DOC programs. From risk management perspective, this approach can also help minimize financial and legal risks to companies.

What Do Claims Management Professionals Need to Know?

Claims adjusters need clear DOC management guidelines at their disposal to handle cases for workers who have experienced a traumatic brain injury and receive a DOC diagnosis.

Injured workers dealing with one of these conditions on a prolonged basis can benefit from a comprehensive DOC treatment program meeting specified criteria. Positive outcomes that reduce costs in the long term typically result from accurately assessing the level of consciousness, implementing interventions that might accelerate the recovery of consciousness, and educating and training caregivers.

Early DOC treatment is likely to minimize complications as well as optimize neurological and functional outcomes. DOC programs can accomplish this by reducing the resources needed to manage secondary complications, including rehospitalization rates, and increase the rate of successful discharge to home-based care.