Vegetative survival: The medical facts and ethical dilemmas

Rehabilitation interventions for vegetative and minimally conscious patients

Brain injury rehabilitation is a complex and challenging task for all members of the multidisciplinary team. Medical advances have allowed more severely impaired patients to survive and consequently the number of patients in the vegetative and minimally conscious states have proportionately increased. Thus, the need for evidence-based practice and further research demonstrating the effects of specific rehabilitation interventions is required. This article reviews the current research and consensus on rehabilitation for patients in the vegetative and minimally conscious states.

Neuropsychological assessment of a potential "euthanasia" case: a 5 year follow up

McMillan reported a neuropsychological assessment procedure which was used to determine whether or not there was evidence for sentience in a young woman who had been rendered tetraplegic and anarthric as a result of a road traffic accident. An application to court had been made to withdraw feeding and this was supported by medical evidence which gave the view that the individual was functioning little beyond vegetative state, had a poor quality of life and had little prospect of further recovery. Evidence for an ability to communicate reliably was found including for a wish to continue living, and as a consequence the application to court was withdrawn. This paper describes further recovery 2-4 years after the original assessment (i.e. 4-6 years post-injury). At follow-up, she remained dependent for all care, but was now feeding orally and was talking. She could learn new information, some of which she retained for at least 12 months and had greater insight into her condition. She now reported low mood and some pain. As before, she consistently reported a wish to live. The implications of the follow-up are discussed in the context of assumptions made about quality of life and decision making about euthanasia in brain injured people who are severely disabled, but are not in a vegetative state.

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.

Motor profile of patients in minimally responsive and persistent vegetative states

The purpose of this descriptive clinical study is to document the motor characteristics of patients in minimally responsive and persistent vegetative states. Twelve subjects, presenting a prolonged altered state of consciousness (x = 7.82 years, range 2-27), aged 27-78 years (x = 50, SD = 15.26) were evaluated, using standardized protocols, on the following variables: passive range of motion, observed movements, reflexes, tonus, postural status and reactions. The subjects' level of awareness and responsivity were measured with the Coma/Near Coma (CNC) scale at each of the three data collection sessions. While group CNC scores were stable over the three sessions, fluctuations in the level of awareness of individual subjects was recorded, confirming the heterogeneity of this clientele. Abnormal primitive reflexes were present in all subjects, with the flexor withdrawal (75%), the tonic labyrinthine (36%) and the body-on-body righting reaction (25%) being the most frequently observed. All subjects presented altered tonus, considerable posturing and varied degrees of reduced range of joint motion. A range of abnormal (e.g. chewing, clonus) and normal patterned (e.g. bridging, scratching) movement behaviours was recorded, but these did not translate into functional use, such as rolling. Collectively, the findings stress the complexity of the motor profile of patients in minimally responsive and vegetative states, and suggest the need for physiotherapists to become more actively involved in the evaluation and treatment of this clientele.

Medical futility decisions and physicians' legal defensiveness: the impact of anticipated conflict on thresholds for end-of-life treatment

Does legal defensiveness significantly influence physicians' assessments of medical futility, in ways that may adversely affect the rights of patients and their family members to make their own health care decisions at the end of life? This exploratory study addresses that question with attitudinal data from a survey of 301 physicians practicing in academic medical centers in Texas. The majority of respondents indicated that the probability of success defining futile treatment should hypothetically be lower for patients with potential to benefit more from life-sustaining medical intervention (e.g. typically patients who are sentient), and higher for patients with less potential to benefit (e.g. patients in a persistent vegetative state). That is to say, physicians normally perceive longer odds to be worth pursuing for greater potential gain - a position that seems logically consonant with patients' rational self-interest. However, physicians with an attitude of extreme legal defensiveness did not fit this pattern. Rather, they tended to define futility in a manner that would maximize the physician's latitude to justifiably oppose patient preferences for end-of-life treatment abatement. These findings suggest that some physicians assume an adversarial position in their consideration of medical futility issues - an attitude that anticipates conflict with terminally-ill patients or their surrogates. The analysis presented here is not definitive, but at least raises the question of whether some physicians may inappropriately use their prerogative over medical futility as a means to guard their professional autonomy against perceived threats.