Assessment after extremely severe head injury in a case of life or death: further support for McMillan

This paper is a sequel to that of McMillan (1997) and describes further assessment of an extremely severely head injured patient. A combination of direct observations, structured interviews with staff, simple cognitive tests and questions with yes/no answers were used to assess communication and cognitive function in an extremely severely head injured patient with minimal ability to respond. Results confirmed the finding of McMillan and showed that the patient could understand and respond consistently to simple commands, could answer simple autobiographical questions consistently and clearly expressed her wish to live. The results of this study and that of McMillan confirm that valid assessment of minimally responsive patients is possible and that a number of different approaches are appropriate.

Belgian doctors' attitudes on the management of patients in persistent vegetative state (PVS): ethical and regulatory aspects

BACKGROUND

The best care and management of patients in persistent vegetative state (PVS) has been the subject of sustained moral and legal debate for a number of years. However, the views of specialist doctors in Belgium involved in the care for patients in PVS are largely unknown.

METHODS

A postal questionnaire was sent to 403 members of Belgian Societies of Neurosurgeons, Neurologists and Rehabilitation Doctors. Their views were sought on various aspects of the management and care of PVS, focusing on the issue of the appropriateness of non-treatment and the withdrawal of artificial feeding.

FINDINGS

Of the 208 doctors who completed the questionnaires (52%), 172 (83%) indicated that they had been involved in the management of a patient in PVS. 88% of the responding doctors thought it was sometimes appropriate not to treat acute infections or other life-threatening conditions in a PVS patient. Fifty-six percent considered it sometimes appropriate to withdraw artificial feeding. About three-quarter of physicians who considered both treatment-limiting decisions appropriate thought that such decisions could be considered within the first year of the patient being in PVS. Forty percent accorded a decisive influence to an advance directive and only a small number of doctors considered the influence of the patient's family in the decision to withdraw artificial feeding as decisive. Over 80% of the clinicians disagreed with the view that each decision about withdrawing artificial nutrition and hydration (ANH) should come before the courts.

INTERPRETATION

Doctors in Belgium seem to be more reluctant to withdraw artificial feeding than not to treat acute infections or other life-threatening conditions in PVS. The reason for this difference appeared to be connected with the moral as well as with the clinical content of the decision. The broad variety of answers on the interval when the vegetative state is to be regarded as permanent and when treatment-limiting decisions are appropriate, could be due to the lack of official guidelines in Belgium. There seems however to be no consensus about a future policy in Belgium for making decisions about the withdrawal of ANH.

[A new formulation of death: definition, criteria and diagnostic tests]

OBJECTIVE

To present a new formulation of human death based on neurological considerations.

DEVELOPMENT

One of the reasons there is still controversy over a new formulation of human death which is acceptable to society, is that many authors do not suitably integrate three fundamental aspects which should be included in such a formulation: definition, criteria and diagnostic tests. We review the physiopathological mechanisms for generation of consciousness and discuss the three fundamental criteria presented by different authors in recent decades: the whole encephalum, brainstem death and neocortical criteria. We conclude that there are major contradictions in the three criteria with regard to satisfactory integration of the elements, definition, criteria and diagnostic tests. We therefore present a new formulation of human death.

DEFINITION

irreversible loss of consciousness, since this gives the essential human attributes, and is the most integrating function of the organism.

CRITERIA

cortico-subcortical connections for the generation of both components of consciousness (capacity and content).

DIAGNOSTIC TESTS

no waking response to stimuli (capacity), no cognitive nor affective functions (content).

CONCLUSIONS

We present a new formulation of human death on a neurological basis which permits satisfactory integration of the three fundamental elements, definition, criteria and diagnostic tests, and so offers a suitable starting point from which man may start to understand death.

The use of limited critical care resources: an ethical dilemma

The following article consists of a review of the literature surrounding the issue of persistent vegetative state (PVS) patients and resource allocation. The author attempts to analyze the question: Should limited critical care resources be used on PVS patients at the risk of denying those resources to others? The author explores such factors as: prognosis and recovery in PVS, life expectancy, and quality of life. As well, resource availability and ICU costs involved in sustaining the life of a PVS patient are examined. Finally, principles such as non-maleficence and beneficence; as well as the critical care professionals attitudes toward this issue; and the moral, ethical, and emotional dilemmas are discussed.

Regional cerebral blood flow changes related to affective speech presentation in persistent vegetative state

A story told by his mother was presented on tape to a trauma patient in persistent vegetative state (PVS). During auditory presentation, measurements of regional cerebral blood flow (rCBF) were performed by means of positron emission tomography (PET). Changes in rCBF related to this stimulus condition, as compared to presenting non-word sound, were evaluated by means of statistical parametric mapping (SPM). This analysis indicated activation of rostral anterior cingulate, right middle temporal and right premotor cortices, which may reflect appropriate cortical involvement in processing emotional attributes of sound or speech.

Misdiagnosis of the vegetative state: retrospective study in a rehabilitation unit

OBJECTIVE

To identify the number of patients who were misdiagnosed as being in the vegetative state and their characteristics.

DESIGN

Retrospective study of the clinical records of the medical, occupational therapy, and clinical psychology departments.

SETTING

20 bed unit specialising in the rehabilitation of patients with profound brain damage, including the vegetative state.

SUBJECTS

40 patients admitted between 1992 and 1995 with a referral diagnosis of vegetative state.

OUTCOME MEASURES

Patients who showed an ability to communicate consistently using eye pointing or a touch sensitive single switch buzzer.

RESULTS

Of the 40 patients referred as being in the vegetative state, 17 (43%) were considered as having been misdiagnosed; seven of these had been presumed to be vegetative for longer than one year, including three for over four years. Most of the misdiagnosed patients were blind or severely visually impaired. All patients remained severely physically disabled, but nearly all were able to communicate their preference in quality of life issues-some to a high level.

CONCLUSIONS

The vegetative state needs considerable skill to diagnose, requiring assessment over a period of time; diagnosis cannot be made, even by the most experienced clinician, from a bedside assessment. Accurate diagnosis is possible but requires the skills of a multidisciplinary team experienced in the management of people with complex disabilities. Recognition of awareness is essential if an optimal quality of life is to be achieved and to avoid inappropriate approaches to the courts for a declaration for withdrawal of tube feeding.

The ultimate curse

This paper tells the story of a doctor in a vegetative state. The approach towards him is quite different from that towards a common patient. The other physicians cannot deal with this situation with the necessary open mind.