69 Prolonged disorders of consciousness: practice described by palliative and rehabilitation physicians

<h3>Introduction</h3> National clinical guidelines for the management of prolonged disorders of consciousness (PDOC) following sudden onset brain injury were updated in 2020. Since the supreme court judgement in 2018, clinical knowledge and management skills have grown. This paper reports current practice. <h3>Methods</h3> A questionnaire was developed, tested and circulated to rehabilitation and palliative medicine specialists, via British Society of Physical and Medical Rehabilitation and Association of Palliative Medicine. Anonymised results and data analysis were stored securely on an NHS server. <h3>Results</h3> 63.5% (n=61) of respondents were involved in the care of people with PDOC, two thirds working in palliative medicine. 44% of clinicians withdraw clinically assisted nutrition and hydration (CANH) in the patient’s usual place of care. Where a decision to admit is taken, 43% will admit to a hospice inpatient unit. 87% of respondents do not arrange long line or central intravenous access prior to withdrawal of CANH. 95% of clinicians prescribe opioids and 92% prescribe sedatives for prn use or directly convert oral/enteral doses to a continuous subcutaneous infusion when withdrawing CANH. Most clinicians titrate according to need. In 81% of cases there was no difficulty with symptom management on withdrawal of CANH. Difficulties encountered included interpretation of movement and symptom assessment (3), care setting (2), agitation (2), thirst (1) and severe secretion burden (1), seizures (1). 48% of respondents worked with staff who expressed a conscientious objection to withdrawal of CANH, 40% in palliative and 66% in rehabilitation medicine. <h3>Conclusion</h3> National guidance should be updated to reflect clinical practice, regarding place of care, the effectiveness of a subcutaneous route and the use of proportionate symptom management. Clinicians caring for people with PDOC should be familiar with the presentation of physiological hyperactivity, symptom assessment in this context, and understand how to escalate concerns. Further research is needed.