Coma Characteristics:
- No eye opening or movement
- No awareness of self or environment
- No ability to follow commands
- No response to voice or noxious stimuli
- No normal sleep-wake cycles
Prognosis:
- Depends on etiology of coma, age of patient, and severity of cause
- Coma rarely lasts > 2-4 weeks, unless sedated or has severe sepsis, as patient either recovers, dies or evolves to another LOC: minimally conscious state, persistent vegetative state, or brain death
Comatose patients with any three of the following on day three of coma (any etiology) eligible hospice referral:
- Abnormal brain stem response
- Absent verbal response
- Absent withdrawal response to pain
- Serum creatinine >1.5 mg/dl
Documentation of the following factors will support eligibility for hospice care:
- Medical complications, in the context of progressive clinical decline, within the previous 12 months, which support a terminal prognosis
- Aspiration pneumonia
- Upper urinary tract infection (pyelonephritis)
- Sepsis
- Refractory stage 3-4 decubitus ulcers
- Fever recurrent after antibiotics
- Diagnostic imaging factors which support poor prognosis after stroke include
- For non-traumatic hemorrhagic stroke
- Large-volume hemorrhage on CT
- Infratentorial greater or equal to 20ml
- Supratentorial greater or equal to 50ml
- Ventricular extension of hemorrhage
- Surface area of involvement of hemorrhage greater or equal to 30%of cerebrum
- Midline shift greater or equal to 1.5cm
- Obstructive hydrocephalus in patient who declines, or is not a candidate for, ventriculoperitoneal shunt
- Large-volume hemorrhage on CT
- For thrombotic/ embolic stroke
- Large anterior infarcts with both cortical and subcortical involvement
- Large bihemispheric infarcts
- Basilar artery occlusion
- Bilateral vertebral artery occusion
- For non-traumatic hemorrhagic stroke
