Wednesday, September 27, 2017

Persistently Unconscious Patient (15 years) Awakened

This article was published on his National Review blog on September 26, 2017

Wesley Smith
By Wesley Smith

Ever since Terri Schiavo, writing about the wrongness of removing feeding tubes from patients diagnosed with persistent unconsciousness (PVS)–we should never call them “vegetables,” a term as denigrating and dehumanizing a racial epithet–is like spitting in the wind. 

But, what the heck. As mentioned above, such patients are often dehydrated to death by having their feeding tubes removed, which takes up to two weeks. 

Never mind that some 40% of such diagnoses are erroneous. Never mind that some of these people may feel the agony of not eating or drinking if so misdiagnosed. Bioethics and law treat artificial nutrition and hydration as a medical treatment, and any medical treatment can be refused or withdrawn. 

But what if scientists found a way to awaken such patients? That may be on the way after an unconscious patients seems to have been roused through nerve stimulation. From the Guardian story
A 35-year-old man who had been in a persistent vegetative state (PVS) for 15 years has shown signs of consciousness after receiving a pioneering therapy involving nerve stimulation. 
The treatment challenges a widely-accepted view that there is no prospect of a patient recovering consciousness if they have been in PVS for longer than 12 months. 
Since sustaining severe brain injuries in a car accident, the man had been completely unaware of the world around him. But when fitted with an implant to stimulate the vagus nerve, which travels into the brain stem, the man appeared to flicker back into a state of consciousness. 
He started to track objects with his eyes, began to stay awake while being read a story and his eyes opened wide in surprise when the examiner suddenly moved her face close to the patient’s. He could even respond to some simple requests, such as turning his head when asked – although this took about a minute. 
This should be good news that should cause us to pause in removing feeding tubes from the unconscious as this research proceeds. (Some bioethicists even want such removals to become the standard of care, say after two years.) 

But I can hear the bioethicists now–because I have read their advocacy: It is more urgent to remove the feeding tubes from the minimally conscious because they may be in horror at their impaired condition or otherwise suffering. And, in fact, people with minimal awareness are legally dehydrated in all fifty states. 

Except–a study of patients in a locked-in state–the appearance of complete unconsciousness but actually aware–shows that most are “happy,” and majorities would not want euthanasia. (Scientists can now communicate with such patients.) 

So, as this research proceeds, let’s care for these seriously disabled patients–both apparently unconscious and conscious–as full and equal members of the moral community, and think twice before removing sustaining treatment that can only have one result; a protracted and perhaps, painful death.


Mark Davis Pickup said...

Thank you for this important and insightful commentary.

Dr. Arnold Voth said...

While I appreciate the very considerable efforts made by the author Wesley Smith on behalf of all pro life people, there are times when his over-simplification of clinical matters risks producing misinformation and this is one of them. He conflates unconsciousness, locked in syndrome and brain death. The three clinical conditions are quite different. The merely unconscious patient in medical parlance has brain function, is capable of responding to at least some stimuli, has an EEG pattern (however abnormal) and is in the technical sense still alive. The patient with a locked in syndrome is most certainly 'alive', can respond to some stimuli and certainly has an EEG pattern. The brain dead patient does not respond to any stimuli whatsoever, is completely or nearly completely flaccid and has a completely flat EEG showing no brain activity at all. The unconscious patient may or may not feel pain or discomfort at various levels. The 'locked-in' patient most certainly does feel pain and discomfort. The brain dead patient has no brain to feel or process any impulses and so does not feel anything. He/she is analogous to the brain dead post trauma victim whose life functions are artificially preserved in order to preserve vital organs for transplant.

Whatever your convictions, these three broad groups of patients cannot be regarded as totally alike. Stopping all nutrition and hydration for the brain dead patient has no consequences for him/her because he no longer exists as a person; only as a brain stem preparation with or without life support. Stopping such support for the locked in patient certainly has consequences for him/her as they still have higher brain functions of pain appreciation and possibly a lot more.

If we treat these groups all the same in our ethical reasoning we will certainly lose any credibility with the larger medical community. The fact that there may be a grey zone between these groups in no way lessens the medical professional's responsibility to make the distinctions as best as he/she can. We deal with grey zones all the time.

Rachael said...

This article should engender in all of us that regardless of our Life condition, time is neither a factor nor a measure of human potential. To receive care, love, dignity til death(as I may occur)and the moral and ethical servitude generated from those in health care, advocates, and personnel surrounding the said person, and I have no doubt family members, is an example of what can be done, what should be done, and dare I say, what will be done for him and others in like circumstances.

Rachael said...

Re Dr Arnold Voth.
He asserts that prolife people are ignorant of the complexities related to health and brain function, citing three categories of medical diagnosis and assessment of the persons life condition and response to stimuli. One must agree to his hypothesis from within the medical establishment point of view.
But! Dr Voth has missed a very crucial point. Regardless of the criteria he has expounded on,It is this.All brain compromised persons are, first and foremost human beings and dependent,and as such, are deserving of all medical, nursing, and nutritional health care until death ultimately occurs. In other words dignity until death. What more??

Gayle said...

Yes, Rachael!

Medical practitioners cannot always explain everything, ie., why some people 'come back', recover from a seemingly hopeless state. Though very knowledgeable, medical practitioners are not God.

...EVEN IF that person in a, so-called, persistent vegetative state (PVS) NEVER recovers from it, but still has all the basic life functions occurring without extraordinary measures, such as machines, to accomplish them, that person is still alive and most certainly does continue to exist as a person, Dr. Voth, because our humanity is not measured only by brain activity. A person in that state deserves basic medical, nursing and nutritional care until natural death.

Dr. Arnold Voth said...

Mostly I agree. But the dilemma for both health care givers and family arise when the patient is in fact already dead - having no brain function. In our way of thinking, when the brain wave pattern is totally flat and remains so for weeks, the patient is dead, regardless of whether there are still rudimentary brain stem activities such as breathing. Currently, I and most of my colleagues, in a case like this will defer to a family and maintain hydration/nutrition. But it is not an approach that can be defended either ethically and certainly not medically. The unconscious patient with full brain wave patterns is easy, we would always persist in our treatment. The 'locked in' patient who is in fact conscious but unable to communicate is also easy. We (or at least, I) would persist indefinitely. But the brain dead patient is a difficult decision - because the patient as such no longer exists. Years ago the English journals reported a case where a young woman several months pregnant was severely brain injured in an accident, maintained on artificial support until the infant could be delivered, when support was withdrawn. An autopsy showed nothing left of the brain but a bit of fluid from autodigestion of the brain. Even if prolife MD's like myself still agree to maintain support for the brain dead patient - it is not a position we can hope to maintain as such cases, thanks to early, skillful resuscitation of especially accident victims, will become ever more common. DIgnity until death - absolutely, but we cannot forever avoid the fact of death.