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Friday, February 05, 2010

Surprise Finding: Some Vegetative Patients May Still Have Consciousness

The debate on what to do with comatose patients becomes slightly more complex, perhaps, with intriguing new findings from the New England Journal of Medicine showing that a minority of completely vegetative patients may be able to hear and respond mentally when spoken to, and may even be able to answer questions. Stories in the press include:Do you remember the Terry Schiavo case? Perhaps a brain scan of this kind might have helped resolve a few questions - if anyone really wanted answers.

With this news from medical science, I hope some of you critics out there won't give up on me completely. Sure, I may seem past hope, but stick me in an MRI and ask me the right questions, and maybe you'll see a little cerebral activity after all.

Update, Feb. 5, 2010: I added the NEJM link so you can read the original study yourself. Very cool.

Additional reading to consider: "The Rom Houben Case: Doctor Explains How He Knows Patient is Conscious." Rom Houben is the Belgian man that appeared vegetative, but was actually aware with nearly normal brain function and was able to communicate accurately using a toe. A technology known as PET revealed the nature of his brain activity. That was the same kind of test that a judge denied for Terry Schiavo, a test that might have resolved the conflicting claims about her responsiveness. See "The Schindlers Were Right to Insist on Tests for Terri."

11 comments:

scw said...

Yeah I remember the Terri Schiavo case, and what a disgrace it was that her situation was tuned into a right-wing propaganda circus. She had a profound brain injury with much of her cerebral cortex destroyed. All brain injuries or comatose states are not created equal. This is not the same case or situation. Do you really want an exsistence where your only communication is a signal seen on fMRI? Besides, no one knows what these signals even mean. Don't beleive the media hype.

Nathan Shumate said...

The big issue for me in the Schiavo case was whether her husband had the right to decide whether to let her die. Whether she was blind or not, whether she was at all responsive or not, the matter came down to whether a spouse has an implicit Power of Attorney to determine end-of-life decisions. My main beef with the people, including her parents, who tried to pull an end-run around her husband was this: We follow the rule of law. If the law is lousy, change it before someone tries to follow it.

Not really the debate you wanted to open up, but...

Anthony said...

Caution: be very skeptical. See that picture on gizmodo.com? It shows distinct activity in a couple of small centers of the brain for both patient and control. Don't you think that the rest of the brain might show a little activity as well? Somehow the researchers masked the rest of the activity, probably using a computer algorithm that is virtually impenetrable even to most specialists. They need to reproduce these results using blinded readers and a lot more patients before they can be considered meaningful.

Jeff, I love you man, but don't you think Terry Schiavo's doctors were interested in having answers? They followed the same procedures used with patients in persistent vegetative states all the time. If society doesn't think those procedures are adequate or ethical, then society ought to agree to change them. But somehow, they didn't.

What exactly was wrong with the way Terry Schiavo was treated by her doctors? Was peristent vegetative state misdiagnosed? That's not impossible. A really good diagnostic test can be wrong 5% of the time. The diagnostic confidence is increased, however, when the results persist for many years, as they did in her case.

Is passive euthenasia in the case of persistent vegetative state unethical? In hundreds of cases so far (Terry schiavo not being unique in that respect), society has answered in the negative. If it is unethical, then maybe we should change the law. Congress and the president acted cynically in this particular case by inserting themselves into a procedure that is normally handled locally. The uncynical thing to do would be to study the issue and decide that if passive euthenasia for persistent vegetation is unethical, then either pass a law that affects more than one person, or stay out of it.

Ranbato said...

While I applaud this study, another point made in the study is that none of the patients in the study with brain injuries like Terri Schiavo were misdiagnosed.

This will be a great tool for people that have other types of injury.

Mormanity said...

Right-wing propaganda circus? Interesting. What would a left-wing propaganda circus look like, scw? The evening news, perhaps? OK, seriously, what examples in recent history would you call left-wing propaganda circuses?

Nathan, wasn't the big issue whether she had consciousness and thus whether it was morally right to dehydrate her to death? If she was aware, how dare we force her to die like that (or in any other way, for that matter). Barbaric.

So was she aware? Anthony, guiven that those who were close to her insisted she was responsive and had video that they felt proved it, there were people interested in getting more conclusive answers. Please recall, though, that a judge blocked the request to get a PET scan that could have determined some aspects of mental awareness. This same technology revealed that Rom Houben, a Belgian man that appeared vegetative, was actually aware with nearly normal brain function. Why not test Terry before taking the risk that an aware human being is painfully dehydrated to death? See "The Schindlers Were Right to Insist on Tests for Terri." I agree with that position.

Mormanity said...

Anthony, thanks for the input. Before getting too skeptical, though, I think you'll enjoy the chance to read the original article, which I should have linked to in the first place. Here it is: http://content.nejm.org/cgi/content/full/NEJMoa0905370. Looks like the doctors are using well known, standard techniques to identify areas of activation that occurs in response to a command given to the patients. Yes, there is brain activity all over. The regions that are colored are done to highlight regions of change. This probably isn't voodoo mysticism, but carefully reviewed science published in the nation's most prestigious (but still fallible) journal of medicine. If a "vegetative" patient is giving similar brain activation patterns as a healthy patient when asked to visualize different activities, there would seem to be good reason to question previous assumptions about vegetative patients. It would also seem wise to at least wonder if we maybe should have given seemingly more responsive patient a chance to be tested, in spite of the severity of her brain injury, before we assumed she was unaware and wouldn't mind being slowly dehydrated. But that's just me.

Just food - and water - for thought.

Clif said...

When I first read about this case study I just shook my head knowing that people would take this one single case and say "AH HA!" - as though this one study suddenly disproved everything we ever knew about neurology.

Come on Jeff. You're a really smart guy. You should know better than that. This is the same kind of flawed logic you debunk when defending the church.

I work as an ICU nurse. Despite having well over a decade of experience in the medical field, I still never cease to be amazed by the ridiculous lengths we will go to keep people alive (while at the same time being completely unwilling to help people who could actually reap significant benefits from adequate health care).

You say it's barbaric to let a patient dehydrate to death. I would submit that it is FAR more barbaric to let such a patient lay in a bed for 16 years to do nothing at all but get tube feedings throughout the day. It also ignores the fact that dying in general is rarely comfortable. Is it somehow worse to dehydrate than it is die from lung disease or cancer?

I would direct your attention to the church's statement on euthanasia and prolonging life...

Members should not feel obligated to extend mortal life by means that are unreasonable.

The entire statement is at:
http://www.newsroom.lds.org/ldsnewsroom/eng/public-issues/euthanasia-and-prolonging-life

scw said...

Jeff: Its a right wing circus when the speaker of the house makes a diagnosis based on a video clip and the President of the United States interrupts one of his many vacations to come back to Washington to sign a bill concerning Schiavo. Its propaganda when the legal cousel for Fla senator Mel Martinez says that Schiavo case offered "a great political issue" that would appeal to the party's base and could be used against Senator Bill Nelson.
And the old canard about the "liberal media"? Give it a rest. Even staunch republicans will admit that its anything but, especially with corporate control of the media. But they sure get a lot of mileage out of it.

Anyway, the real issue is that Schiavo had a profound anoxic brain injury. Nothing was going to fix that. She was just unfortunate enough to have enough brain stem functions preserved so she could breath on her own. Like Clif, I have seen and dealt with many profoundly ill patients. Its not pretty. I encourage use of a living will so that your wishes for end of life issues are known prior to some devastating injury.

Another point- in the article, only 5 out of the 54 patients they studied had any response. None of those patients had anoxic brain injury, the type that Terri Schiavo had. Obviously, not all brain injuries, or vegetative states, are created equal. Even the authors allow that the one patient who showed awareness could have regained some ability over time, and was correctly diagnosed when he was first admitted. This study will generate media hype, like it has, and then will probably be forgotten as future studies fail to confirm the findings.

Anthony said...

Jeff,

Thanks for the link. My skepticism stems from the small number of patients involved in the study. The radiology literature generally suffers from low numbers of study subjects. It's a weakness in the field. The paper's authors should tell us whether the people asking questions to the patients were unaware of the answers, so as not to inadvertently stimulate the patients using unconscious cues. That may seem nit picky, but horses can appear to do math due to the unconscious cues received from their owners. Additionally, before this study could be used clinically, we would need to show that a radiologist could correctly interpret the MRI without knowing the status of the patients or the correct answers to the questions.

Regarding your other point about Terry Schiavo and PET, the sensitivity and specificity of PET for diagnosing persistent vegetative state is still under investigation. The gold standard for making the diagnosis remains clinical (i.e. bedside neurologic examination). Consequently, it's very difficult to show that PET provides additive diagnostic information above and beyond the clinical exam. Based upon the appearance of Terry Schiavo's CT scans, her PET scan definitely would have been very abnormal. It would have been impossible to distinguish persistent vegetative state from minimally conscious based upon the PET data, so the judge made the right decision. (Whether he made it for the right reasons, I couldn't say.)

Terry Schiavo's doctors had something much more reliable than a PET scan. They knew her clinical condition for a 15 year period. How do we know when persistent vegetative state is misdiagnosed? The patient shows awareness weeks, months, or years later. Terry didn't do that.

Anthony said...

And Jeff,

Rom Houben's case is quite different from Terry Schiavo's. From the link that you provided, Dr. Laureys says:

"And he showed minimal signs of consciousness. So we didn’t even need fancy scanning methods to change the diagnosis."

So according to Rom's doctor, the PET scan wasn't necessary to overturn the diagnosis. This underscores my earlier point about PET not necessarily providing additive diagnostic value over the clinical exam.

Dr. Laureys also says,

"We wrote a paper on this in Lancet Neurology in 2004, in which we reviewed how PET scanning has shown high metabolic levels in the brains of patients in a locked-in syndrome compared with those in a vegetative state. However, what is still a major challenge is to disentangle vegetative from a minimally conscious state and other disorders of consciousness. This is not as black and white."

So Dr. Laureys agrees that we don't yet know how to use PET to distinguish minimally conscious from PVS. Terry Schiavo was either minimally conscious or PVS, so PET wouldn't have helped.

Mormanity said...

Cliff, thanks, and I appreciate your expertise in the area, which I lack. I will admit that I have a hard time not being influenced by the statements of Terry's family, who felt that giving food and water was not an unreasonable means to keep someone alive whom they loved and whom they saw - so they claim - responding to them, s if there were still some awareness left. Maybe the right thing was done, it's possible and perhaps even likely if the medical diagnosis were accurate, but there are elements of the case and of global trends to accept euthanasia and assisted suicide that leave me quite unsettled.