Abstract
Purpose
To generate foundational knowledge in the creation of a quality-of-life instrument for patients who are clinically diagnosed as being in a vegetative or minimally conscious state but are able to communicate by modulating their brain activity (i.e., behaviourally nonresponsive and covertly aware). The study aimed to identify a short list of key domains that could be used to formulate questions for an instrument that determines their self-reported quality of life.
Methods
A novel two-pronged strategy was employed: (i) a scoping review of quality-of-life instruments created for patient populations sharing some characteristics with patients who are behaviourally nonresponsive and covertly aware was done to compile a set of potentially relevant domains of quality of life; and (ii) a three-round Delphi consensus process with a multidisciplinary panel of experts was done to determine which of the identified domains of quality of life are most important to those who are behaviourally nonresponsive and covertly aware. Five expert groups were recruited for this study including healthcare workers, neuroscientists, bioethicists, quality-of-life methodologists, and patient advocates.
Results
Thirty-five individuals participated in the study with an average response rate of 95% per round. Over the three rounds, experts reached consensus on 34 of 44 domains (42 domains were identified in the scoping review and two new domains were added based on suggestions by experts). 22 domains were rated as being important for inclusion in a quality-of-life instrument and 12 domains were deemed to be of less importance. Participants agreed that domains related to physical pain, communication, and personal relationships were of primary importance. Based on subgroup analyses, there was a high degree of consistency among expert groups.
Conclusions
Quality of life should be a central patient-reported outcome in all patient populations regardless of patients’ ability to communicate. It remains to be determined how covertly aware patients perceive their circumstances and quality of life after suffering a life-altering injury. Nonetheless, it is important that any further dialogue on what constitutes a life worth living should not occur without direct patient input.
Similar content being viewed by others
References
Maas, A. I., et al. (2017). Traumatic brain injury: Integrated approaches to improve prevention, clinical care, and research. The Lancet Neurology,16(12), 987–1048.
Gean, A. D., & Fischbein, N. J. (2010). Head trauma. Neuroimaging Clinics,20(4), 527–556.
Greenwald, B., & Nori, P. (1995). Disorders of consciousness. Manual of Traumatic Brain Injury Management,1, 199.
Payne, K., et al. (1996). Physicians’ attitudes about the care of patients in the persistent vegetative state: a national survey. Annals of Internal Medicine,125(2), 104–110.
Laureys, S., Owen, A. M., & Schiff, N. D. (2004). Brain function in coma, vegetative state, and related disorders. The Lancet Neurology,3(9), 537–546.
Owen, A. M., et al. (2006). Detecting awareness in the vegetative state. Science,313(5792), 1402.
Monti, M. M., et al. (2010). Willful modulation of brain activity in disorders of consciousness. New England Journal of Medicine,362(7), 579–589.
Fernández-Espejo, D., & Owen, A. M. (2013). Detecting awareness after severe brain injury. Nature Reviews Neuroscience,14(11), 801.
Naci, L., & Owen, A. M. (2013). Making every word count for nonresponsive patients. JAMA Neurology,70(10), 1235–1241.
Kondziella, D., et al. (2016). Preserved consciousness in vegetative and minimal conscious states: Systematic review and meta-analysis. Journal of Neurology, Neurosurgery and Psychiatry,87(5), 485–492.
WHOQOL Group. (1995). The World Health Organization quality of life assessment (WHOQOL): Position paper from the World Health Organization. Social Science and Medicine,41(10), 1403–1409.
Pietersma, S., de Vries, M., & van den Akker-van, M. E. (2014). Domains of quality of life: Results of a three-stage Delphi consensus procedure among patients, family of patients, clinicians, scientists and the general public. Quality of Life Research,23(5), 1543–1556.
Keeney, S., McKenna, H., & Hasson, F. (2010). The Delphi technique in nursing and health research. Hoboken: Wiley.
Hsu, C.-C., & Sandford, B. A. (2007). Minimizing non-response in the Delphi process: How to respond to non-response. Practical Assessment, Research & Evaluation,12(17), 62–78.
Borgiel, A. E., et al. (1989). Recruiting family physicians as participants in research. Family Practice,6(3), 168–172.
Skulmoski, G. J., Hartman, F. T., & Krahn, J. (2007). The Delphi method for graduate research. Journal of Information Technology Education: Research,6, 1–21.
Skevington, S. M. (1998). Investigating the relationship between pain and discomfort and quality of life, using the WHOQOL. Pain,76(3), 395–406.
Naci, L., et al. (2012). Brain–computer interfaces for communication with nonresponsive patients. Annals of Neurology,72(3), 312–323.
Acknowledgements
We would like to thank the members of the expert panel for lending their time and expertise, and without whom this work would not have been possible. Members of the expert panel included Salman Abbasi (Patient and Family Advisor), Ruth Barclay (University of Manitoba), John Gordon Boyd (Queens University), Linda Bruni (Patient and Family Advisor), Srivas Chennu (University of Kent), Joyce Cramer (Yale University), Damian Cruse (University of Birmingham), Athena Demertzi (University of Liège), David Feeny (McMaster University), Brian Feldman (University of Toronto), Davina Fernández-Espejo (University of Birmingham), Paola Finoia (Cambridge University), Teneille Gofton (Western University), Mackenzie Graham (Oxford University), Jennifer Hawkins (Duke University), Gil Hersch (George Mason University), Terry Howard (Patient and Family Advisor), Guy Kahane (Oxford University), Nadira King (Patient and Family Advisor), Ayse Kuspinar (University of Waterloo), Marcello Massimini (University of Milan), Nancy Mayo (McGill University), Lorina Naci (Trinity College Dublin), Margarita Perez (Patient and Family Advisor), Andrew Peterson (George Mason University), Leonard Rodrigues (Patient and Family Advisor), Keith Sequeira (Western University), Anthony Skelton (Western University), Jeanne Teitelbaum (University of Montreal), Juan Torres (Patient and Family Advisor), Andrea Townson (University of British Columbia), Paul and Jeff Tremblay (Patient and Family Advisor), Alexis Turgeon (Université de Laval), Samuel Wiebe (University of Calgary), and Bryan Young (Western University).
Funding
This project was funded by an operating grant from the Canadian Institutes of Health Research (MOP-133705).
Author information
Authors and Affiliations
Corresponding author
Ethics declarations
Conflict of interest
Charles Weijer receives consulting income from Eli Lilly & Company Canada. The other authors have no competing interests to declare.
Ethical approval
Approval for this study was obtained from the Western University Health Science Research Ethics Board (#108066). Informed consent was obtained from all participants included in this study.
Additional information
Publisher's Note
Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
Rights and permissions
About this article
Cite this article
Tung, J., Speechley, K.N., Gofton, T. et al. Towards the assessment of quality of life in patients with disorders of consciousness. Qual Life Res 29, 1217–1227 (2020). https://doi.org/10.1007/s11136-019-02390-8
Accepted:
Published:
Issue Date:
DOI: https://doi.org/10.1007/s11136-019-02390-8