A disorder of consciousness (DoC) is a state where consciousness has been
affected by damage to the brain. DoC range in the form of a hierarchy, including coma,
vegetative state and minimally conscious state. The most common way to assess
consciousness is to observe their responses to stimulation. However, observing these
responses and detecting purposeful behaviours is extremely challenging. Several
studies have shown that misdiagnosis is common. It is crucial to optimise the way
consciousness assessments are performed. Clinical management of DoC patients, from
treatment of pain to end-of-life decisions, depends on behavioural observations. In the
present chapter, we review the challenges posed by the assessment of consciousness
and the importance of combining clinical assessment with complementary methods of
assessment, such as positron emission tomography, functional magnetic resonance
imaging and electroencephalography. According to the diagnosis established, the
patient will follow different care pathways. Although therapeutic options of DoC are
still limited, basic therapies include artificial nutrition and hydration, physical and
occupational therapies as well as sensory stimulation. Pharmacologic trials, deep brain
stimulation and multisensory stimulations are some of the therapeutic options for
DoCs. Recently, it was removed the requirement to obtain legal sanction for every
decision to withdraw clinically assisted nutrition and hydration from people in DoCs.
This has led to an entire paradigm shift, from a focus on the diagnosis to a focus on the
patient’s best interest. Although these decisions will spare the courts’ involvement, one
should never disregard reaching a correct diagnosis for this vulnerable population.
Keywords: Anoxia, Assessment, Brain injury, Coma, Consciousness, Diagnosis,
Disorders of consciousness, Emergence, Minimally conscious state, Misdiagnosis,
Prognosis, Treatment, Vegetative state.
