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PubMed1994

Medical aspects of the persistent vegetative state (1).

This consensus statement of the Multi-Society Task Force summarizes current knowledge of the medical aspects of the persistent vegetative state in adults and children. The vegetative state is a clinical condition of complete unawareness of the self and the environment, accompanied by sleep-wake cycles, with either complete or partial preservation of hypothalamic and brain-stem autonomic functions. In addition, patients in a vegetative state show no evidence of sustained, reproducible, purposeful, or voluntary behavioral responses to visual, auditory, tactile, or noxious stimuli; show no evidence of language comprehension or expression; have bowel and bladder incontinence; and have variably preserved cranial-nerve and spinal reflexes. We define persistent vegetative state as a vegetative state present one month after acute traumatic or nontraumatic brain injury or lasting for at least one month in patients with degenerative or metabolic disorders or developmental malformations. The clinical course and outcome of a persistent vegetative state depend on its cause. Three categories of disorder can cause such a state: acute traumatic and non-traumatic brain injuries; degenerative and metabolic brain disorders, and severe congenital malformations of the nervous system. Recovery of consciousness from a posttraumatic persistent vegetative state is unlikely after 12 months in adults and children. Recovery from a nontraumatic persistent vegetative state after three months is exceedingly rare in both adults and children. Patients with degenerative or metabolic disorders or congenital malformations who remain in a persistent vegetative state for several months are unlikely to recover consciousness. The life span of adults and children in such a state is substantially reduced. For most such patients, life expectancy ranges from 2 to 5 years; survival beyond 10 years is unusual.

Coma↗
PubMed1993

Medical futility, treatment withdrawal and the persistent vegetative state.

Why do we persist in the relentless pursuit of artificial nourishment and other treatments to maintain a permanently unconscious existence? In facing the future, if not the present world-wide reality of a huge number of persistent vegetative state (PVS) patients, will they be treated because of our ethical commitment to their humanity, or because of an ethical paralysis in the face of biotechnical progress? The PVS patient is cut off from the normal patterns of human connection and communication, with a life unlike other forms of human existence. Why the struggle to justify ending a life which, it is said, has suffered an irreversible loss of the content of consciousness? Elsewhere, the authors have addressed the ethical controversies and confusion engendered by ambiguous terminology, misuse of medical facts and the differing interpretations of what constitutes 'effective' treatment: in particular, the issue of whether in fact artificial nutrition and hydration is a medical treatment, or simply part of the obligatory care owed to all patients, permanently unconscious or not. In this paper, we intend to argue that recent analyses of medical futility, its meaning and ethical implications, despite an absence of public consensus, permit some tentative re-evaluation of our ethical obligations to the PVS patient.

Coma↗
PubMed1998

[Persistent vegetative state: medical, moral, legal and economic aspects].

The classical definition of persistent vegetative state describes patient who is wakeful but not awake, and indicates intact function of the brain stem and no function of brain cortex. The presence and the degree of awareness is most difficult to assess and causes moral and legal controversies concerning the management of persistent vegetative state. The absence of the perceptual awareness may be the most important clinical characterization for diagnosis. Differential diagnosis includes coma, brain death, locked-in syndrome and minimally responsive state. The pressure of economical factors (managed care) on medical care makes this problem even more complicated.

Brain Death↗
PubMed1997

Persistent vegetative state and brain stem death.

Interest in the persistent vegetative state has focused on the accuracy of diagnosis and prognosis. Retrospective studies in both adult and paediatric groups have raised questions about the most appropriate clinical methods to diagnose patients in the vegetative state and about the length of time before recovery from such a state can be regarded as hopeless. Although no absolute answers have been forthcoming, the debate engendered by the work has been informative and the need for further prospective studies is apparent. Following the publication of guidelines on the management of patients in the vegetative state, the views of physicians in the USA and Europe have been sought in relation to ethical problems and, although they highlight some areas of inconsistency, they show the potential for consensus. Clinically, the field of brain stem death is reasonably defined and consistently managed but the search for methods of technical confirmation of diagnosis continues. It is suggested that the use of magnetic resonance imaging and angiography might provide additional confirmatory evidence.

Animals↗
PubMed1981

Five-year follow-up study of patients with persistent vegetative state.

One hundred and ten patients with persistent vegetative state, were followed up for a period of five years from 1973 to 1978. Seventy-three per cent of the patients died during the period while about 10% of them recovered partially from the vegetative state. Among the recovered patients, only three became able to communicate, but two of these are not independent for their daily activites. Reactivity and clinical symptoms of 30 survivors were examined, but no great changes occurred during the last two years of the study.

Adult↗
PubMed2000

Withdrawal of artificial nutrition in the persistent vegetative state: a continuous controversy.

The withdrawal of life support from patients in persistent vegetative state (PVS) is a controversial issue, as highlighted by a continuous public debate and recent judicial decisions. In Germany, a topic of particular interest is the abatement of artificial nutrition. First, doubts have come up whether every kind of technically delivered nutrition should be rated identically or whether a distinction between feeding tubes/gastrotomies and intravenous administration should be made. Second, the question is left open whether artificial nutrition is part of basic care and as a consequence may never be discontinued, or if it has to be regarded as life-sustaining treatment which can be refused by surrogates on behalf of the nonautonomous patient. Most recently, controversial judicial decisions have dealt with the question if substituted judgement concerning abatement of artificial nutrition by surrogates or legal guardians is permitted or if the approval of a court is necessary. Forensic evidence is provided which indicates that the withdrawal of artificial nutrition in patients in the persistent vegetative state may become a contributing causative factor or even the immediate cause of death. The legal implications with regard to the above-mentioned issues of controversy are discussed.

Enteral Nutrition↗
PubMedDate not supplied

Deep-brain stimulation in a persistent vegetative state: follow-up results and criteria for selection of candidates.

Eight cases of a persistent vegetative state caused by brain damage were treated by chronic deep-brain stimulation (stimulation target: the mesencephalic reticular formation and/or non-specific thalamic nucleus) over a period of more than 6 months. Three of the patients are currently able to communicate and to express their demands by voice and one other patient has recovered very close to this state. These four cases showed changeable spectrograms with desynchronization on continuous EEG recording and all components of the BSR and SER could be recorded except for prolonged latency of both N20 (SER) and the V wave (BSR) 2 months after the initial coma. Following chronic deep-brain stimulation, EEG and behavioural arousal responses were observed with increased r-CBF, r-CMRO2 and r-CMRGL in the whole brain tissue. After 3-6 months of chronic deep brain stimulation, the prolonged coma scale rose in four of the eight cases and three cases emerged from the persistent vegetative state. Transmitter substances and their metabolites were also found to be increased in the CSF after chronic deep-brain stimulation. Based on these findings, chronic deep-brain stimulation represents a useful kind of treatment that can lead to emergence from a persistent vegetative state, if the candidate is selected by electrophysiological studies 2 months after the initial insult and if the stimulation is applied for more than 6-8 months using a high-safety chronic deep-brain stimulating instrument.

Adult↗
PubMed1997

Persistent vegetative state in Alzheimer disease. Does it exist?

OBJECTIVE: To determine if the published criteria for diagnosis of the persistent vegetative state could be applied to patients suffering from Alzheimer disease. DESIGN AND METHODS: Eighty-eight institutionalized patients with a diagnosis of possible or probable Alzheimer disease were evaluated for the presence of persistent vegetative state. Initial screening excluded patients who were able to do any of the following: feed themselves, respond to command, walk, or maintain continence of bowel and bladder. A sample of 12 of 28 patients unable to perform any of these functions was examined independently by 3 of us. RESULTS: During the first examination, 2 patients were diagnosed as being in a vegetative state by 2 of us and 3 additional patients by 1 of us. One of us did not diagnose any patient as being in a vegetative state. A second evaluation of the same patients was performed 2 months later, after holding a consensus meeting to standardize the evaluation procedure. During the second evaluation, the vegetative state was diagnosed in 6 patients but only by 1 of us. CONCLUSION: The diagnostic disagreement between the neurologists indicate that Alzheimer disease may only rarely progress to the persistent vegetative state.

Aged↗
PubMed2005

Circadian blood pressure and heart rate changes in patients in a persistent vegetative state after traumatic brain injury.

Alteration of autonomic nervous system regulation is known to be present in the persistent vegetative state after traumatic brain injury, termed the dysautonomic syndrome. This study assessed the circadian blood pressure and heart rate pattern and variability in the persistent vegetative state through noninvasive 24-hour ambulatory blood pressure monitoring. The study was performed in 20 subjects: 10 patients (six men and four women; mean age, 29.5+/-9.9 years; range, 19-39 years) in a vegetative state (mean, 27.3+/-5.6 days after trauma) and 10 healthy subjects as controls (six men and four women; mean age, 28+/-5.7 years; range, 29-37 years). The patients showed a blood pressure nondipper pattern; 24-hour, daytime, and nighttime values of blood pressure and heart rate were significantly higher in patients than in controls. The day-night difference in heart rate and blood pressure was also significantly lower in patients. Finally, SD and variation coefficients were significantly lower in patients. The results show changes in the variability and circadian blood pressure and heart rate patterns in persistent vegetative state patients with dysautonomic syndrome, as an expression of the sympathetic-parasympathetic activity imbalance in the control of vasomotor tone.

Adult↗
PubMed2000

Early indication of emergence from vegetative state derived from assessments with the SMART--a preliminary report.

An explanatory analysis of data from serial assessments of 30 patients with a diagnosis of vegetative state (persistent vegetative state) was carried out. The data were gathered using the Sensory Modality Assessment and Rehabilitation Technique (SMART) and the Western Neuro Sensory Stimulation Profile (WNSSP) on the same day in the week post-admission and, thereafter, at 2 monthly intervals. Seven patients emerged from vegetative state during the study, a further six emerged later (by time of the analysis) and the rest remained in vegetative state. Recovery scores were calculated for each measure by subtracting the total score at any one assessment from the total score for the subsequent assessment; the largest recovery scores, shown by each patient, were noted. It was found that those who emerged later could be differentiated mathematically from those who did not emerge, using largest recovery score data from the SMART. This research supports previous

Adolescent↗
PubMed1989

Brain death and the persistent vegetative state: similarities and contrasts.

Brain death and the persistent vegetative state (PVS) share the following features: 1.) There is death of neurons in the brain; 2.) Both require an etiology which is capable of causing neuronal death. 3.) The potential for cognition is totally and permanently lost; 4.) Intensive medical support is usually withdrawn. In contrast, the diagnosis of brain death depends on death of the brainstem, while PVS implies permanent and total loss of forebrain function. While brainstem death can be diagnosed clinically, accurate prognosis in PVS requires additional investigation. Thus far, the EEG is the most specific test of neuronal function in the cerebral cortex. Brain death is equivalent to death, while PVS is not; management of the latter is more complex because of medical, social, ethical and legal factors.

Brain Death↗
PubMed1990

Persistent vegetative state and the decision to withdraw or withhold life support. Council on Scientific Affairs and Council on Ethical and Judicial Affairs.

Persons with overwhelming damage to the cerebral hemispheres commonly pass into a chronic state of unconsciousness (ie, loss of self-awareness) called the vegetative state. When such cognitive loss lasts for more than a few weeks, the condition has been termed a persistent vegetative state, because the body retains the functions necessary to sustain vegetative functions. Recovery from the vegetative state does occur, but many persons in persistent vegetative states live for months or years if provided with nutritional and other supportive measures. The withdrawal of life support from these persons with loss of higher brain function is a controversial issue, as highlighted by public debates and judicial decisions. This article provides criteria for the diagnosis of permanent unconsciousness and reviews the available data that support the reliability of these criteria. Significant legal decisions have been made with regard to withdrawal of life support to patients in persistent vegetative states, and the trends in this area are discussed.

American Medical Association↗
PubMedDate not supplied

Residual auditory function in persistent vegetative state: a combined PET and fMRI study.

In recent years, a number of studies have demonstrated an important role for functional neuroimaging in the identification of residual cognitive function in persistent vegetative state. Such studies, when successful, may be particularly useful where there is concern about the accuracy of the diagnosis and the possibility that residual cognitive function has remained undetected. Unfortunately, functional neuroimaging in persistent vegetative state is extremely complex and subject to numerous methodological, clinical and theoretical difficulties. Here, we describe the strategy used to study residual auditory and speech processing in a single patient with a clinical diagnosis of persistent vegetative state. Identical positron emission tomography studies, conducted nine months apart, revealed preserved and consistent responses in predicted regions of auditory cortex in response to intelligible speech stimuli. Moreover, a preliminary functional magnetic resonance imaging examination at the time of the second session revealed partially intact responses to semantically ambiguous stimuli, which are known to tap higher aspects of speech comprehension. In spite of the multiple logistic and procedural problems involved, these results have major clinical and theoretical implications and provide a strong basis for the systematic study of possible residual cognitive function in patients diagnosed as being in a persistent vegetative state.

Adult↗
PubMed1996

Survey of British clinicians' views on management of patients in persistent vegetative state.

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 clinicians in the UK involved in caring for patients in PVS are largely unknown. METHODS: A postal questionnaire was sent to 1882 consultant members of the British Association of Orthopaedic Surgeons, the Association of British Neurologists, the Society of British Neurosurgeons, and the British Society of Rehabilitation Medicine. Their views were sought on various aspects of the management and care of PVS, in particular the appropriateness of a decision not to treat and a decision to withdraw artificial nutrition and hydration (ANH). FINDINGS: 1027 doctors responded (55%) of whom 558 (54%) had experience of managing patients in PVS. Over 90% of responding doctors considered that it could be appropriate not to treat acute infections and other life-threatening conditions. 65% of doctors considered that withdrawal of ANH could be appropriate. About two-thirds of doctors who thought treatment-limiting decisions could be appropriate thought that such decisions could be considered with the first 12 months of the patient being in PVS. Despite recent case law, less than half the doctors responding to the survey thought that an advance directive made by the patient should have a decisive influence in determining treatment-limiting decisions. Most doctors would like decisions about withdrawing ANH to be made in conjunction with family members and in accordance with agreed guidelines but without the need to go to court. INTERPRETATION: There is a broad consensus among doctors that treatment-limiting decisions are sometimes appropriate for patients in PVS, irrespective of whether they have experience of the condition or of the specialty to which they belong. However, two thirds of doctors said that such decisions can be considered at a time earlier than that recommended by the British Medical Association. It is not clear why some doctors thought a decision not to treat could be appropriate while a decision to withdraw ANH would not be.

Advance Directives↗
PubMed2003

Do we need stimulation programs as a part of nursing care for patients in "persistent vegetative state"? A conceptual analysis.

The rehabilitative care of persons suffering long-lasting effects of brain injury is a significant challenge for nurses as they are the health professionals who usually spend the most time with them. Historically in Germany, the term "apallic syndrome" has been commonly used for what Plum and Posner (1980) termed the persistent vegetative state. When persons are diagnosed as being in a persistent vegetative state, that is awake but not aware, for more than six months, they seldom receive active therapy except what nurses or families may provide. Stimulation programs have been advocated for these persons, but there is still no reliable evidence as to their effectiveness, and the conceptual basis of the two main types of programs has been poorly understood. The multisensory stimulation approach, such as the Coma Recovery Program or Coma Arousal Therapy, is based on behaviourism with the belief that intensive stimulation provided to all senses will enhance synaptic reinnervation and stimulate the reticular activating system to increase brain tone. In contrast, the sensory regulation approach is based on information processing and mediation of reaction to sensory information with emphasis on enhancing selective attention by regulating the environment rather than providing high degrees of stimulation. What both approaches have in common is the belief that the person in a persistent vegetative state may, at some level, be able to perceive and begin to process information and that external stimulation may enhance that process. Nurses interacting with persons in persistent vegetative state are encouraged to think about how they can regulate sensory input to enhance meaning and facilitate information processing for these persons.

Arousal↗
PubMedDate not supplied

PET of infant in persistent vegetative state.

This is the first report of cranial positron emission tomography findings of an infant in a persistent vegetative state. Serial positron emission tomography/2-deoxy-2[18F]fluoro-D-glucose studies demonstrated persistent global reduction of cerebral glucose metabolism, results similar to those found in adults in persistent vegetative states. Positron emission tomography may be useful in confirming this clinical diagnosis in infants.

Blood Glucose↗
PubMed2005

Instability of spontaneous breathing patterns in patients with persistent vegetative state.

We investigated the breathing patterns of 27 patients in a persistent vegetative state (PVS) and 15 normal control volunteers. During the baseline period breathing air, 15 patients (the PVS-IB) exhibited irregular breathing (IB), whereas the other 12 (the PVS-OB) displayed oscillatory breathing (OB). Both groups maintained an average value for tidal volume (V(T)), total breath duration (T(TOT)), minute ventilation (V (E)), oxygen saturation (SpO2) similar to the control, but the PVS-OB displayed significantly lower end-tidal CO2 tension (P(ET)CO2) than the control. The V(T), T(TOT), V (E) and P(ET)CO2 of the PVS-OB showed cyclic changes. The coefficients of variation of V(T), T(TOT) and V (I) were: PVS-OB>PVS-IB>control. Inhalation of 100% O2 significantly reduced the respiratory variability and prevented OB of the PVS-OB. We concluded that PVS patients display respiratory instability and that brain damage, hypocapnia, and/or increased loop gain of arterial chemoreceptors may contribute to the pathogenesis of OB, whereas brain damage presumably may be the cause of IB.

Aged↗