People in vegetative states

Great Debates
1

How do you decide whether or not to pull the plug? I realize this is a messy topic, and there are a lot of different scenarios. I’m bringing this topic up now because it now may be possible to revive vegetative patients to minimal consciousness using drugs (Ambien, actually). So the chance of a recovery of some sort is much higher now, assuming this technique is reliable. Does this change your answer from before?

I’d prefer to only consider the case where the patient has not asked beforehand to have the plug pulled in case of this happening.

2

I would think financial consideration has to enter into it eventually. Should you be expected to go into terrible debt for a loved one?

3

It’s a complicated question, and the fact that we’re learning a lot about these states of consciousness is fascinating and makes it more complicated: it does sound like some patients who have been diagnosed as vegetative might be more conscious than we’d assumed. The Ambien story shows that some patients can improve unexpectedly, and some continue to improve over time or get better spontaneously, but others don’t. We have little to no ability to predict who will get better or who won’t.

That’s an overly optimistic reading of the story. Some patients in minimally conscious states - not vegetatives states - have been helped by Ambien. For a few, there is a big improvement and it may even be a springboard to greater recovery. Some keep taking it for a long time but without a sustained improvement. Others stop responding to it after a while.

Answer to what?

4

Answer to whether or not to keep a family member on life support. Like the family in the article with their son.

The way I read the article is that it’s now more likely to go from vegetative to minimal consciousness. Or does the drug only give temporary consciousness to those who are already minimally conscious? It was unclear.

The bigger picture is that we are now learning far more about consciousness and it’s a far more complicated subject than it was just a few years ago.

5

It’s a very hard decision, and not to give a total cop out, but it depends very much on the circumstances - particularly (for me) how much brain damage the person may have suffered. My general inclination would be to pull the plug. Ultimately I don’t think being minimally conscious is a life most people would want to live even if it’s not the same thing as being vegetative.

The Ambien thing only works on people who are minimally conscious. The article says that Chris was originally expected to be permanently vegetative but is now minimally conscious. That was because his brain recovered somewhat, not because of the Ambien. That came later.

Yes, it is.

6

If there was a reasonable chance these people could come back to some semblance of a normal life, I’d be loathe to pull the plug.

But the reality is, unless you come out of coma type injury pretty quickly (within 12 months for blunt force trauma and less for other injuries, as per the article) then your long term prognosis just is not good at all.

It is true that some people in persistent vegetative states are actually in minimally conscious states, as the article explained it requires lots of continuous observation by a doctor to discern one from the other; and because of that it is often the case that minimally conscious people are diagnosed as being in a persistent vegetative state.

However, the best case scenario for these people in minimally conscious states is they end up like the Dutch guy mentioned in the article (the one they discovered the Ambien cure with; not the son primarily featured in the article) he’s returned to some level of normalcy albeit with severe physical handicaps and some lingering and probably permanent mental handicaps. However, that guy is genuinely “conscious” now and has some form of real life.

The son, on the other hand, seems like he’s mostly still just minimally conscious. Which means he can barely respond to any stimuli, he is (even with drugs) only intermittently able to have any communications. He can barely communicate and only then when under the drugs, he has extreme physical handicaps which are almost certainly permanent. Hell, if I was that guy I can say right now I’d rather be dead. I’d actually rather be in a persistent vegetative state than what that guy has, he’s in essentially a coffin-body, locked in for the rest of his life with minor periods in which he can vaguely recognize and respond to what is going on around him. That’s a living hell worse than the oblivion of death, at least to me, and worse than the bliss of someone who is in a persistent vegetative state and thus essentially totally unaware.

With stuff like this there has been “weird” things like this for awhile now. Back in the 70s they found that giving people in catatonic states who had been brain damaged from encephalitis massive doses of Parkinson’s drugs could “awaken” them, but invariably they built up a tolerance to the drug and were returned to the prison of their bodies.

I know a family whose son went away for college and ended up getting viciously assaulted in an argument on the streets late at night. Ever since that day he has been on the borderline between a persistent vegetative state and a minimally conscious state, he’s essentially been like that for 18 months now and while you’d never say it near the family the truth is that timeline means he’s pretty much gone forever. His best hope is something like this, but even that would mean his parents might be able to communicate with him in some rudimentary fashion for a few hours a week, but he’d still be unable to move, unable to enjoy life, unable to talk, unable to do anything…and in this kid’s case they’ve already tried some of the experimental stuff (like implanting electrodes into the brain to try and stimulate it) and nothing has worked to even allow him the minimal responsiveness of the son mentioned in this news article.

This situation has literally destroyed this boy’s family, and I’ve known families that have lost children and this is honestly worse than that. People I’ve known who lose children are permanently scarred by the experience, but most of them get to move on and have a life, and eventually they are able to emotionally get past it. But in this kid’s case, his parents are trapped, they can never get past his situation because he is not dead, but is a constant physical reminder of the son they lost. The father has quit his job and devotes pretty much his every waking hour to the constant care of his son, and to be honest it is literally killing him; I would not be shocked to see him die before his time. While I’d never say it in person, I feel that this family would have been done a great kindness if their son had died instead of been kept alive in the hospital that first night of his injury.

Personally I have a living will for this sort of thing, and it would definitely lead to me being disconnected long before such a situation. I think in general doctors are doing the right thing when they gently suggest removing the ventilator, because that’s a much easier decision to make when you see the person’s brain is essentially destroyed. However when it persists for long enough that the person’s body can breathe again on its own, the only way to end the life is to remove the feeding tube, which is far more difficult emotionally because you are essentially starving your child to death–even one in a permanent vegetative state that is a horrifically difficult thing to have done.

7

This reminds me of the sensationalism surrounding the Terri Schiavo case. Her parents were locked in a legal battle with Terri’s husband: the parents wanted Terri left alone, and her husband had made the gut-wrenching decision to withdraw her feeding tube.

The news only presented the parents’ POV, and that of the Catholic Church. A video clip was played which showed Terri apparently responding to her mother’s voice. The parents felt like this was indicative that the Terri they knew was still “in there,” and they wanted to keep their daughter as long as possible. Of course, the Church trotted out its “Right to Life” teaching.

There was a LOT more to the story.

Terri had apparently suffered cardiac arrest due to an electrolyte imbalance, and she fell into a coma. After two and a half months, this was “upgraded” to persistent vegetative state.

What most people don’t know is that her husband was actively involved in aggressive treatment to rehabilitate Terri. He became a registered nurse, and he researched all types of rehabilitation. Terri received some type of settlement, and he used that money to transport her to California from Florida, for deep brain stimulation treatment.

By 1993, Terri’s husband came to the realization that there was no hope to Terri’s recovery. He made the decision to include a DNR into her medical records.

It was determined that Terri’s brain had no recoverable tissue. There remained enough for her to live, but just barely. Along with the portion to think and to reason, she had lost all physical control of her body, and here is the kicker: the vision portion of her brain was gone. After brain cell death as extensive as Terri had suffered, the skull is filled with non specific “goo.”

The fact there was a public and bitter battle between Terri’s parents and her husband made this case a household word at the time. The attempted intervention by Governor Jeb Bush, the US Congress, and even President George HW Bush takes the case into the realm of ridiculous. While it is understandable that the parents were loath to bid farewell to their daughter, they simply should have stepped aside and let Terri’s husband make whatever legal decisions he felt necessary. This recent development to “restore persistent vegetative states to minimal consciousness” in my opinion, will just increase the chances that other families will take their battles into the court of public opinion, to permit them to feed their false hopes. Terri Schiavo died in 1990. Her physical body was allowed to follow the journey of her brain in 2005.

(scroll down about 1/3 the way to see the brain CT scan)

It’s extremely difficult to lose a beloved family member to death. To drag out the death for years is unconscionable.
~VOW

8

Yes, I’m well aware of the Schiavo case, although I didn’t know she was in an “unrecoverable” state. As you said the media was rather one-sided on the subject.

One of the reasons why I brought this topic up (after it’s been debated to death previously on these boards) was because I wanted to get the straight dope on that article (because it was quite optimistic for a NYT article almost to the point of glurge) as well as any new medical developments on the subject.

9

If you read through the sensationalism, Schiavo was genuinely in a persistent vegetative state and not a minimally conscious state. I don’t know that anyone has ever truly recovered from a persistent vegetative state, but rather some individuals who were minimally conscious were early-on misdiagnosed as being in a persistent vegetative state and then later had a brief recovery.

This stuff is rare though, there’s a guy who was in a car injury who came back after 20 years. There was a fire fighter who came back years and years after an on the job injury, and was fully cognizant for a few days (or weeks?) but then suddenly died. There is this Dutch kid mentioned in the article.

These aren’t just “tips of the iceberg” these are almost the totality of people making “full” recoveries from being gone for that number of years. There’s a few more out there, but we aren’t talking rare, we’re talking ultra/super-rare.

Now, don’t get me wrong, some people do get injured and go into a coma and come out, with varying degrees of brain damage (or some with minimal damage.) However by definition when someone has entered a true persistent vegetative state they’ve been gone for longer than most medical fact would suggest is possible to be gone and then come back.

The guy who was gone for some 20 years after a car accident and then just woke up, was actually in a minimally conscious state, a state that as this article indicates carries some hope; but the hope is small. Coming back from a true persistent vegetative state, without some miracle of medicine that can recreate destroyed brain tissue en masse (and even then we get into speculation as to what would happen if you could truly rebuild a brain, would the original personality and memories come back, or would you essentially be grafting a healthy brain onto the body of someone whose original personality and memories are permanently gone?) is essentially impossible.

So coming back from a PVS is like as impossible as a minor league team winning the World Series, coming back from a minimally conscious state is about as likely as the Chicago Cubs winning the World Series next year.

It is very, very difficult to distinguish between these two states as that article illustrates. A lot of doctors will basically just see some guy in a vegetative state and leave it at that, distinguishing between the different levels of consciousness just isn’t important to them in terms of providing care. Even the doctor that finally conceded the son was in a minimally conscious state had to basically be forced by the parents into observing him for a lengthy period of time. The doctor in the article who is an expert on these matters has said that a lot of parents will be very desperate to believe their child in a vegetative state is in a minimally conscious state, and will state discerning random tics or movements as signs of interaction, but when the doctor applies his more scientific testing over a long period of time, usually these end up being nothing, sometimes they are a sign of real response to stimuli, though.

However Schiavo isn’t like say, the guy in the car accident who came back after 20 years. That guy was basically looked at for a few months and then doctors back in the 80s wrote him off as a permanently “gone” person, he was shipped to a long term care facility and that was that, his diagnosis was never really analyzed beyond that and then one day he woke up.

Schiavo was under massive scrutiny because of the celebrity nature of the case, and thus she was not comparable to that guy. She was studied extensively and all of the results showed true physical destruction and death of her brain, she was a very solid PVS diagnosis based on far more attention that probably any person in such a state has ever received before or sense.

There was also a guy from Belgium who was in a diagnosed persistent vegetative state for 23 years, it ends up he was fully conscious the whole time, but almost the entirety of his body was paralyzed and thus he had no way to respond to anyone. However, more advanced brain imaging, which was not available in the 1980s when he was injured, proved that his brain was actually alive and well. Eventually they set him up with a rig where he can use a single finger to perform rudimentary communication. That was essentially a failure of medical science as it was in the 80s, but again, Schiavo wasn’t someone who no one had looked at her with modern medical equipment since her initial injury; she was put under the most rigorous lens of pretty much anyone ever in such a state and all of the tests came back showing her brain was essentially destroyed.

(For reference, the car crash victim who spontaneously “awoke” after almost 20 years was Terry Wallis, the Belgian who had been secretly conscious for 23 years was Rom Houben , and the firefighter who awoke briefly but then died was Donald Herbert.)

10

I would concede that there needs to be a concerted effort to determine if a patient is in a persistent vegetative state, or a minimally conscious state.

And I would emphatically encourage EVERYONE to make their wishes known as to how these two diagnoses should be handled by the next of kin.

The public battle between Terri’s husband and Terri’s parents was unconscionable. It deteriorated into muckraking, and only served to drag out the inevitable.

Although the situations were NOT the same, I had to make end-of-life decisions for both of my parents. I knew what their wishes were, and despite any emotional desires on my behalf, I know I did the right thing for them, per their expressed determinations. I expect my husband and/or my children to do the same thing for me, as I would do for my husband.

And I specifically told my son-in-law that I would NOT interfere in his decision making, should he ever be in the same horrible position as Terri Schiavo’s husband.

“a time to weep and a time to laugh, a time to mourn and a time to dance.”
~VOW

11

Schiavo’s parents still insist that she wasn’t in PVC, could have been cured, that all the damage showed in the autopsy was a result of her dehydration and starvation, and to cast Michael Schiavo as the bad guy, and possibly the guy that caused her initial injuries.

Mark Fuhrman (yes, the OJ guy) wrote a book “The Only Living Witness” supporting Schiavo’s parent’s claims. I felt he had been given a raw deal till I read this tome. t is an abomination.

12

Among the problems is that making this determination takes time. As the Times article details, you can only pull the plug while the patient is on a ventilator- and once they can breathe on their own, it’s no longer an option. If it becomes clear after that they won’t recover, you’re faced with options like withholding nutrition or medical care, which people find more difficult.

13

People who are confined to a bed in any kind of health care facility that houses many patients are subject to infection: respiratory, kidney, skin.

The next of kin can make a determination to NOT treat the infection. Simply state to the care provider, “I don’t want my family member to have any antibiotics.”

That decision is NOT considered to be inhumane, and in the case of a person in an end-of-life scenario, antibiotics can be construed as an extreme measure to prolong life.

This was the decision my family and I made when my mother had her last hospitalization. We knew she would never improve. She wasn’t coming home. Prolonging her life as it was would be against her expressed wishes.

In my father’s case, he had had major surgery, and he wasn’t recovering as expected. The doctors were using drugs to support his blood pressure, and they were out of any more choices. My sister and I decided to just have ALL drugs withdrawn. Again, these drugs were considered to be extreme measures, in that he was not expected to recover, and the drugs were only postponing the inevitable.

There are other means to withdraw from a person in a persistent vegetative state, other than “unplugging the respirator.” The removal of these means, usually supportive drugs like antibiotics or blood pressure regulating drugs, is not a cruel method, nor is it illegal or immoral.

It’s hard to lose a loved one. But there is some consolation in knowing you’ve done absolutely the right thing.
~VOW

14

Yes, I mentioned that: it’s withholding medical care. I don’t think it’s wrong, but I think people may find it more difficult and may not see the situations as similar. A death from not treating an infection takes longer, and as I think the article also pointed out, Catholic teachings (for example) make a distintion between not taking extraordinary steps like using a ventilator and actively withholding care, like letting an infectino runs its course.

15

Death in a person already physically debilitated by being in a persistent vegetative state takes mere days. A fever unchecked can reach 104-105 degrees quite rapidly, and death is imminent then. Death by withholding nutrition/hydration can take a lot longer.

I don’t think the Catholic Church considers antibiotics on the same level as nutrition/hydration.

I, personally, have no qualms about withholding antibiotics or, as in the case of my father, blood pressure regulatory drugs. However, I would not be able to withhold nutrition or hydration.

I do admit that nutrition via an NG tube or via a central line is invasive and unnatural, and besides that, it looks incredibly uncomfortable.

But that’s just me.
~VOW

16

My general understanding is that the RCC says moral to withhold treatment to let an illness take its course, but it’s not OK to stop treating someone if that will kill them. I don’t know where antibiotics fit into that. I’m not Catholic and I don’t much care about these distinctions; I’m just pointing out that they matter to some people and it’s another reason it makes it harder to make this decision.

17

Trust me, Marley, it’s a hard, hard decision no matter what faith you hold, if any. It’s absolutely heartbreaking.

The wishes of the patient should supercede everyone else’s “choice,” and it is absolutely crucial that every single person discuss this particular topic with friends and family.
~VOW

18

Man, that’s tough. I’ve been around too much death recently, and I would probably agree with you that this is worse. Life can be so cruel!

19

I hereby announce my wishes, right here on SDMB, for the public record:

If I am ever in a profoundly disabled state, either mentally or physically, such that I am deemed unable to (mentally or physically) communicate my wish to live or die, and it seems that there is little chance of any substantial recovery, then I want a life-maintaining medical treatment (including nutrition and hydration) terminated, and instead, I want to be placed on a maximally palliative treatment regimen (up to and possibly including terminal palliative sedation) until I die.

If I am thought to be in some kind of “minimally conscious state”, I think that might likely be a horrendous way to exist. I think that would likely be far worse than being totally unconscious or vegetative. Thus, I think the idea of keeping someone alive because they are (or are thought to be) “minimally conscious” is just crazy.

ETA: I express this attitude for myself only.

NYT columnist Gail Collins wrote an essay to this effect several years ago. Maybe, just maybe, I can find a link to it.

20

Those news were (as if you didn’t know it) biased; among many other biases they forgot that the RCC also teaches that extraordinary measures are just that, extra-ordinary and it’s perfectly fine to renounce their use; also that the right to life isn’t merely a right to breathe, but to a life “with dignity” (translating from Spanish here, not sure what the right terms are in English).