Pundole, Amy; (2025) Improving assessment of functional communication to identify emergence from a Prolonged Disorder of Consciousness (PDOC). Doctoral thesis (Ph.D), UCL (University College London).

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Abstract

Adults in a prolonged disorder of consciousness (PDOC) must demonstrate functional object use or functional communication to establish emergence from this state. However, current emergence criteria are narrow, and clinicians are uncertain regarding tasks and stimuli to use. Accurate diagnosis is vital to support decision making for ongoing treatment including the continuation of clinically assisted nutrition and hydration. This PhD explored assessment of functional communication to identify emergence from PDOC. It reports three phases of research. First, an online survey of expert clinicians in the UK established current opinion and practice when assessing emergence. Most survey respondents (78%) indicated they worked with patients who they considered to have emerged, but who did not fit the current criteria for emergence. Approximately one third (30.4%) used tasks other than those which are recommended to determine emergence, and almost half (46.4%) reported a lack of confidence in current tasks. A second experimental study explored the impact of task and stimuli on response accuracy in 12 patients emerging from PDOC. Spoken word-to-colour/object matching tasks were found to significantly improve response accuracy compared to yes/no questions, and responses to colour stimuli were significantly more accurate than for objects. Yes/No situational questions from the recommended CRS-R assessment scored lowest. The final study comprised an exploratory linguistic ethnographic analysis to capture how three adults emerging from PDOC interact with others in a range of natural contexts. Patients emerging from PDOC demonstrated a breadth of interaction behaviours, employing gesture, facial expression, body movement and vocalisation, and interaction partners employed various techniques to promote agency. Findings will be used to update local policy and national guidelines, support the development of context-based assessment, and develop communication partner training to elicit interaction behaviours from emerging patients.

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