Deep brain stimulation for whom? The challenges of patient selection
Deep brain stimulation is an approved and effective neurosurgical intervention for motor disorders such as Parkinson’s disorder and essential tremor. It is an experimental procedure for the treatment of a number of psychiatric conditions, namely the treatment of refractory depression. In Parkinson’s disease, DBS alleviates some of the symptoms of the disorders and may improve the quality of life in daily tasks, but does not cure. It is an invasive and expensive procedure usually used as a last resort treatment, when medication and all other treatments have failed. For all these reasons, carefully selecting appropriate candidates is of utmost importance.
Ethically speaking, ideal candidates for DBS are those “who will obtain and retain the greatest benefit from a DBS intervention and who are physically, cognitively and emotionally capable of tolerating surgery and participating in their own postoperative care” (Bell et al, 2009: 579). Selection would be best achieved by the combined expertise of a multidisciplinary team capable of assessing the diagnosis, the cognitive and psychiatric status of patients and their overall potential for success. Among other things, the selection process should allow to identify possible comorbid conditions often associated with neurological and mental disorders.
Selection of patients should also assess the latter’s commitment and access to social support. DBS requires a large amount of time, energy and sometimes travel before and after surgery for screening appointments, device checks, programming, medication management, etc. For instance, it can take up to 8 appointments during the 6 months period following surgery to program the frequency and rate of electric stimulation provided by a pulse generator implanted in the patient’s chest to ensure optimal results and comfort. Moreover, the treatment is mostly offered in research centres which may require that patients travel long distance several times. For all these reasons, commitment to the treatment regimen and social support are necessary. Of course, there is no doubt that patients without social support should still be offered all opportunities for equal access to the therapy but these aspects should be acknowledged so that support is put into place to optimize follow-up success.
Finally, patients’ expectations should be carefully evaluated, understood and discussed. As mentioned before, DBS is not a cure. The risks of disappointment or perceived failure are high, even more so in the case of psychiatric patients where DBS is still experimental. In this domain, expectations of success remain ill defined. Thus, patients should be made aware of the probability of failure and should understand the range of possible impacts of the intervention on their symptoms.
This text summarises the ethical issues related to deep brain stimulation, developed and discussed in an excellent publication by Emily Bell, Ghislaine Mathieu and Eric Racine. (2009). Preparing the ethical future of deep brain stimulation. Surgical Neurology, 72: 577-586. The summary has been approved by the first author.
|Adapted by :||Myriam Hivon, Ph.D.|
Bell E, Mathieu G, Racine E (2009). Preparing the ethical future of deep brain stimulation. Surgical Neurology, 72: 577-586.