Persistent vegetative state

From Wikipedia, the free encyclopedia

Persistent vegetative state
ICD-9 780.03
MeSH D018!8
" persistent vegetative state is a disorder of conscio#sness in $hich patients $ith severe %rain damage are in a
state of partial aro#sal rather than tr#e a$areness. &t is a diagnosis of some #ncertainty in that it deals $ith a
syndrome. "fter fo#r $eeks in a vegetative state '()*, the patient is classified as in a persistent 'or
+contin#ing+* vegetative state. ,his diagnosis is classified as a permanent vegetative state 'P()* some months
after a non-tra#matic %rain in.#ry '3 months in the /)", 0 months in the /1, or one year after tra#matic in.#ry.
Contents
1 Definition
o 1.1 2edical definition
o 1.3 4ack of legal clarity
3 5istory
3 6lassification
)igns and symptoms
! 6a#ses
0 Diagnosis
o 0.1 Diagnostic e7periments
o 0.3 2isdiagnoses
7 8ecovery
8 Possi%le treatment and c#res
o 8.1 9olpidem
o 8.3 4evodopa
o 8.3 :aclofen
o 8. 8emoval of cold int#%ated o7ygen
o 8.! :ifocal e7trad#ral cortical stim#lation
; <pidemiology
10 <thics and policy
11 =ota%le P() patients
13 )ee also
13 =otes
1 8eferences
1! F#rther reading
Definition
Medical definition
" $akef#l #nconscio#s state that lasts longer than a fe$ $eeks is referred to as a persistent 'or +contin#ing+*
vegetative state.
>1?>3?
Lack of legal clarity
/nlike %rain death, permanent vegetative state 'P()* is recogni@ed statute as death in very fe$ legal systems.
&n the /), co#rts have reA#ired petitions %efore termination of life s#pport that demonstrate that any recovery
of cognitive f#nctions a%ove a vegetative state is assessed as impossi%le %y a#thoritative medical opinion.
>3?
&n
<ngland and Wales the legal precedent for $ithdra$al of clinically assisted n#trition and hydration in cases of
patients in a P() $as set in 1;;3 in the case of "nthony :land, $ho s#stained catastrophic ano7ic %rain in.#ry
in the 1;8; 5ills%oro#gh disaster.
>1?
"pplication to the 6o#rt of Protection is still no$ reA#ired %efore n#trition
and hydration can %e $ithdra$n or $ithheld from P() 'or +minimally conscio#s+ - 26)* patients 8oyal
6ollege of Physicians 3013 Prolonged Disorders of 6onscio#snessB =ational 6linical C#idelines,
httpsBDD$$$.rcplondon.ac.#kDreso#rcesDprolonged-disorders-conscio#sness-national-clinical-g#idelines.
,his legal grey area has led to vocal advocates that those in P() sho#ld %e allo$ed to die. Ethers are eA#ally
determined that, if recovery is at all possi%le, care sho#ld contin#e. ,he e7istence of a small n#m%er of
diagnosed P() cases that have event#ally res#lted in improvement makes defining recovery as Fimpossi%leF
partic#larly diffic#lt in a legal sense.
>?
,his legal and ethical iss#e raises A#estions a%o#t a#tonomy, A#ality of
life, appropriate #se of reso#rces, the $ishes of family mem%ers, and professional responsi%ilities.
History
,he syndrome $as first descri%ed in 1;0 %y <rnst 1retschmer $ho called it apallic syndrome.
>!?
,he term
persistent vegetative state $as coined in 1;73 %y )cottish spinal s#rgeon :ryan Gennett and "merican
ne#rologist Fred Pl#m to descri%e a syndrome that seemed to have %een made possi%le %y medicine+s increased
capacities to keep patients+ %odies alive.
>0?>7?
Classification
,here are several definitions that vary %y technical vers#s laymen+s #sage. ,here are different legal implications
in different co#ntries.
The vegetative state is a chronic or long-term condition. ,his condition differs from a comaB a coma is a state
that lacks %oth a$areness and $akef#lness. Patients in a vegetative state may have a$oken from a coma, %#t
still have not regained a$areness. &n the vegetative state patients can open their eyelids occasionally and
demonstrate sleep-$ake cycles, %#t completely lack cognitive f#nction. ,he vegetative state is also called a
Fcoma vigilF. ,he chances of regaining a$areness diminish considera%ly as the time spent in the vegetative
state increases.
>8?
The persistent vegetative state is the standard #sage 'e7cept in the /1* for a medical diagnosis, made after
n#mero#s ne#rological and other tests, that d#e to e7tensive and irrevoca%le %rain damage a patient is highly
unlikely ever to achieve higher f#nctions a%ove a vegetative state. ,his diagnosis does not mean that a doctor
has diagnosed improvement as impossi%le, %#t does open the possi%ility, in the /), for a .#dicial reA#est to end
life s#pport.
>?
&nformal g#idelines hold that this diagnosis can %e made after fo#r $eeks in a vegetative state.
/) casela$ has sho$n that s#ccessf#l petitions for termination have %een made after a diagnosis of a persistent
vegetative state, altho#gh in some cases, s#ch as that of ,erri )chiavo, s#ch r#lings have generated $idespread
controversy.
&n the /1, the term +persistent vegetative state+ is disco#raged in favor of t$o more precisely defined terms that
have %een strongly recommended %y the 8oyal 6ollege of Physicians '86P*. ,hese g#idelines recommend
#sing a continos vegetative state for patients in a vegetative state for more than fo#r $eeks. " medical
definition of a permanent vegetative state can %e made if, after e7ha#stive testing and a c#stomary 13 months
of o%servation,
>;?
a medical diagnosis that it is impossible %y any informed medical e7pectations that the mental
condition $ill ever improve.
>10?
5ence, a Fcontin#o#s vegetative stateF in the /1 may remain the diagnosis in
cases that $o#ld %e called FpersistentF in the /) or else$here.
While the act#al testing criteria for a diagnosis of FpermanentF in the /1 are A#ite similar to the criteria for a
diagnosis of FpersistentF in the /), the semantic difference imparts in the /1 a legal pres#mption that is
commonly #sed in co#rt applications for ending life s#pport.
>;?
,he /1 diagnosis is generally only made after
13 months of o%serving a static vegetative state. " diagnosis of a persistent vegetative state in the /) #s#ally
still reA#ires a petitioner to prove in co#rt that recovery is impossi%le %y informed medical opinion, $hile in the
/1 the FpermanentF diagnosis already gives the petitioner this pres#mption and may make the legal process
less time-cons#ming.
>?
&n common #sage, the FpermanentF and FpersistentF definitions are sometimes conflated and #sed
interchangea%ly. 5o$ever, the acronym FP()F is intended to define a Fpersistent vegetative stateF, $itho#t
necessarily the connotations of permanence, and is #sed as s#ch thro#gho#t this article.
:ryan Gennett, $ho originally coined the term Fpersistent vegetative stateF, has no$ recommended #sing the
/1 division %et$een contin#o#s and permanent in his most recent %ook The Vegetative State. ,his is one for
p#rposes of precision, on the gro#nds that Fthe +persistent+ component of this term ... may seem to s#ggest
irreversi%ilityF.
>0?
,he "#stralian =ational 5ealth and 2edical 8esearch 6o#ncil has s#ggested Fpost coma #nresponsivenessF as
an alternative term for Fvegetative stateF in general.
>11?
Signs and symptoms
2ost P() patients are #nresponsive to e7ternal stim#li and their conditions are associated $ith different levels
of conscio#sness. )ome level of conscio#sness means a person can still respond, in varying degrees, to
stim#lation. " person in a coma, ho$ever, cannot. &n addition, P() patients often open their eyes in response to
feeding, $hich has to %e done %y othersH they are capa%le of s$allo$ing, $hereas patients in a coma s#%sist
$ith their eyes closed '<mmett, 1;8;*.
P() patients+ eyes might %e in a relatively fi7ed position, or track moving o%.ects, or move in a disconjugate
'i.e. completely #nsynchroni@ed* manner. ,hey may e7perience sleep-$ake cycles, or %e in a state of chronic
$akef#lness. ,hey may e7hi%it some %ehaviors that can %e constr#ed as arising from partial conscio#sness,
s#ch as grinding their teeth, s$allo$ing, smiling, shedding tears, gr#nting, moaning, or screaming $itho#t any
apparent e7ternal stim#l#s.
&ndivid#als in P() are seldom on any life-s#staining eA#ipment other than a feeding t#%e %eca#se the
%rainstem, the center of vegetative f#nctions 's#ch as heart rate and rhythm, respiration, and gastrointestinal
activity* is relatively intact '<mmett, 1;8;*.
Cases
,here are three main ca#ses of P() 'persistent vegetative state*B
1. "c#te tra#matic %rain in.#ry
3. =on-tra#maticB ne#rodegenerative disorder or meta%olic disorder of the %rain
3. )evere congenital a%normality of the central nervo#s system
2edical %ooks 's#ch as 4ippincott, Williams, and Wilkins. '3007*. &n " PageB Pediatric )igns and )ymptoms*
descri%e several potential ca#ses of P(), $hich are as follo$sB
:acterial, viral, or f#ngal infection, incl#ding meningitis
&ncreased intracranial press#re, s#ch as a t#mor or a%scess
(asc#lar press#re $hich ca#ses intracranial hemorrhaging or stroke
5ypo7ic ischemic in.#ry 'hypotension, cardiac arrest, arrhythmia, near-dro$ning*
,o7ins s#ch as #remia, ethanol, atropine, opiates, lead, colloidal silver
>13?
,ra#maB 6onc#ssion, cont#sion
)ei@#re, %oth nonconv#lsive stat#s epileptic#s and postconv#lsive state 'postictal state*
<lectrolyte im%alance, $hich involves hyponatremia, hypernatremia, hypomagnesemia, hypoglycemia,
hyperglycemia, hypercalcemia, and hypocalcemia
Postinfectio#sB "c#te disseminated encephalomyelitis '"D<2*
<ndocrine disorders s#ch as adrenal ins#fficiency and thyroid disorders
Degenerative and meta%olic diseases incl#ding #rea cycle disorders, 8eye syndrome, and mitochondrial
disease
)ystemic infection and sepsis
5epatic encephalopathy
&n addition, these a#thors claim that doctors sometimes #se the mnemonic device "<&E/-,&P) to recall
portions of the differential diagnosisB "lcohol ingestion and acidosis, <pilepsy and encephalopathy, &nfection,
Epiates, /remia, ,ra#ma, &ns#lin overdose or inflammatory disorders, Poisoning and psychogenic ca#ses, and
)hock.
Diagnosis
Despite converging agreement a%o#t the definition of persistent vegetative state, recent reports have raised
concerns a%o#t the acc#racy of diagnosis in some patients, and the e7tent to $hich, in a selection of cases,
resid#al cognitive f#nctions may remain #ndetected and patients are diagnosed as %eing in a persistent
vegetative state. E%.ective assessment of resid#al cognitive f#nction can %e e7tremely diffic#lt as motor
responses may %e minimal, inconsistent, and diffic#lt to doc#ment in many patients, or may %e #ndetecta%le in
others %eca#se no cognitive o#tp#t is possi%le 'E$en et al., 3003*. &n recent years, a n#m%er of st#dies have
demonstrated an important role for f#nctional ne#roimaging in the identification of resid#al cognitive f#nction
in persistent vegetative stateH this technology is providing ne$ insights into cere%ral activity in patients $ith
severe %rain damage. )#ch st#dies, $hen s#ccessf#l, may %e partic#larly #sef#l $here there is concern a%o#t
the acc#racy of the diagnosis and the possi%ility that resid#al cognitive f#nction has remained #ndetected.
Diagnostic e!periments
8esearchers have %eg#n to #se f#nctional ne#roimaging st#dies to st#dy implicit cognitive processing in
patients $ith a clinical diagnosis of persistent vegetative state. "ctivations in response to sensory stim#li $ith
positron emission tomography 'P<,*, f#nctional magnetic resonance imaging 'f28&*, and electrophysiological
methods can provide information on the presence, degree, and location of any resid#al %rain f#nction. 5o$ever,
#se of these techniA#es in people $ith severe %rain damage is methodologically, clinically, and theoretically
comple7 and needs caref#l A#antitative analysis and interpretation.
For e7ample, P<, st#dies have sho$n the identification of resid#al cognitive f#nction in persistent vegetative
state. ,hat is, an e7ternal stim#lation, s#ch as a painf#l stim#l#s, still activates +primary+ sensory cortices in
these patients %#t these areas are f#nctionally disconnected from +higher order+ associative areas needed for
a$areness. ,hese res#lts sho$ that parts of the corte7 are indeed still f#nctioning in +vegetative+ patients
'2ats#da et al., 3003*.
&n addition, other P<, st#dies have revealed preserved and consistent responses in predicted regions of a#ditory
corte7 in response to intelligi%le speech stim#li. 2oreover, a preliminary f28& e7amination revealed partially
intact responses to semantically am%ig#o#s stim#li, $hich are kno$n to tap higher aspects of speech
comprehension ':oly, 300*.
F#rthermore, several st#dies have #sed P<, to assess the central processing of no7io#s somatosensory stim#li
in patients in P(). =o7io#s somatosensory stim#lation activated mid%rain, contralateral thalam#s, and primary
somatosensory corte7 in each and every P() patient, even in the a%sence of detecta%le cortical evoked
potentials. &n concl#sion, somatosensory stim#lation of P() patients, at intensities that elicited pain in controls,
res#lted in increased ne#ronal activity in primary somatosensory corte7, even if resting %rain meta%olism $as
severely impaired. 5o$ever, this activation of primary corte7 seems to %e isolated and dissociated from higher-
order associative cortices '4a#reys et al., 3003*.
"lso, there is evidence of partially f#nctional cere%ral regions in catastrophically in.#red %rains. ,o st#dy five
patients in P() $ith different %ehavioral feat#res, researchers employed P<,, 28& and
magnetoencephalographic '2<C* responses to sensory stim#lation. &n three of the five patients, co-registered
P<,D28& correlate areas of relatively preserved %rain meta%olism $ith isolated fragments of %ehavior. ,$o
patients had s#ffered ano7ic in.#ries and demonstrated marked decreases in overall cere%ral meta%olism to 30I
0J of normal. ,$o other patients $ith non-ano7ic, m#ltifocal %rain in.#ries demonstrated several isolated
%rain regions $ith higher meta%olic rates, that ranged #p to !0I80J of normal. =evertheless, their glo%al
meta%olic rates remained K!0J of normal. 2<C recordings from three P() patients provide clear evidence for
the a%sence, a%normality or red#ction of evoked responses. Despite ma.or a%normalities, ho$ever, these data
also provide evidence for locali@ed resid#al activity at the cortical level. <ach patient partially preserved
restricted sensory representations, as evidenced %y slo$ evoked magnetic fields and gamma %and activity. &n
t$o patients, these activations correlate $ith isolated %ehavioral patterns and meta%olic activity. 8emaining
active regions identified in the three P() patients $ith %ehavioral fragments appear to consist of segregated
corticothalamic net$orks that retain connectivity and partial f#nctional integrity. " single patient $ho s#ffered
severe in.#ry to the tegmental mesencephalon and paramedian thalam#s sho$ed $idely preserved cortical
meta%olism, and a glo%al average meta%olic rate of 0!J of normal. ,he relatively high preservation of cortical
meta%olism in this patient defines the first f#nctional correlate of clinicalI pathological reports associating
permanent #nconscio#sness $ith str#ct#ral damage to these regions. ,he specific patterns of preserved
meta%olic activity identified in these patients reflect novel evidence of the mod#lar nat#re of individ#al
f#nctional net$orks that #nderlie conscio#s %rain f#nction. ,he variations in cere%ral meta%olism in chronic
P() patients indicate that some cere%ral regions can retain partial f#nction in catastrophically in.#red %rains
')chiff et al., 3003*.
Misdiagnoses
2isdiagnosis of P() is not #ncommon. Ene st#dy of 0 patients in the /nited 1ingdom reported that 3J of
those patients classified as in a P() $ere misdiagnosed and another 33J a%le to recover $hilst the st#dy $as
#nder$ay.
>13?
)ome cases of P() may act#ally %e cases of patients %eing in an #ndiagnosed minimally
conscio#s state.
>1?
)ince the e7act diagnostic criteria of the minimally conscio#s state $ere form#lated only in
3003, there may %e chronic patients diagnosed as P() %efore the notion of the minimally conscio#s state
%ecame kno$n.
Whether or not there is conscio#s a$areness in vegetative state is a prominent iss#e. ,hree completely different
aspects of this iss#e sho#ld %e disting#ished. First, some patients can %e conscio#s simply %eca#se they are
misdiagnosed 'see a%ove*. &n fact, they are not in vegetative state. )econd, sometimes a patient $as correctly
diagnosed %#t, then, e7amined d#ring a %eginning recovery. ,hird, perhaps some day the very notion of the
vegetative state $ill change so as to incl#de elements of conscio#s a$areness. &na%ility to disentangle these
three cases leads to conf#sion. "n e7ample of s#ch conf#sion is the response to a recent e7periment #sing
magnetic resonance imaging $hich revealed that a $oman diagnosed $ith P() $as a%le to activate predicta%le
portions of her %rain in response to the tester+s reA#ests that she imagine herself playing tennis or moving from
room to room in her ho#se. ,he %rain activity in response to these instr#ctions $as indisting#isha%le from those
of healthy patients.
>1!?>10?>17?
&n 3010, 2artin 2onti and fello$ researchers, $orking at the 286 6ognition and :rain )ciences /nit at the
/niversity of 6am%ridge, reported in an article in the =e$ <ngland Go#rnal of 2edicine
>18?
that some patients in
persistent vegetative states responded to ver%al instr#ctions %y displaying different patterns of %rain activity on
f28& scans. Five o#t of a total of ! diagnosed patients $ere apparently a%le to respond $hen instr#cted to
think a%o#t one of t$o different physical activities. Ene of these five $as also a%le to Fans$erF yes or no
A#estions, again %y imagining one of these t$o activities.
>1;?
&t is #nclear, ho$ever, $hether the fact that
portions of the patients+ %rains light #p on f28& co#ld help these patients ass#me their o$n medical decision
making.
>1;?
&n =ovem%er 3011, a p#%lication in The Lancet presented %edside <<C apparat#s and indicated that its signal
co#ld %e #sed to detect a$areness in three of 10 patients diagnosed in the vegetative state.
>30?
"ecovery
2any patients emerge spontaneo#sly from a vegetative state $ithin a fe$ $eeks.
>0?
,he chances of recovery
depend on the e7tent of in.#ry to the %rain and the patient+s age I yo#nger patients having a %etter chance of
recovery than older patients. " 1;; report fo#nd that of those $ho $ere in a vegetative state a month after a
tra#ma, !J had regained conscio#sness %y a year after the tra#ma, $hereas 38J had died and 18J $ere still
in the vegetative state. :#t for non-tra#matic in.#ries s#ch as strokes, only 1J had recovered conscio#sness at
one year, 7J had died, and 3;J $ere still vegetative. Patients $ho $ere vegetative si7 months after the initial
event $ere m#ch less likely to have recovered conscio#sness a year after the event than in the case of those $ho
$ere simply reported vegetative at one month.
>31?
" =e$ )cientist article from 3000 gives a pair of graphs
sho$ing changes of patient stat#s d#ring the first 13 months after head in.#ry and after incidents depriving the
%rain of o7ygen.
>33?
"fter a year, the chances that a P() patient $ill regain conscio#sness are very lo$
>citation needed?
and most patients $ho do recover conscio#sness e7perience significant disa%ility. ,he longer a patient is in a
P(), the more severe the res#lting disa%ilities are likely to %e. 8eha%ilitation can contri%#te to recovery, %#t
many patients never progress to the point of %eing a%le to take care of themselves. 8ecovery after long periods
of time in a P() has %een reported on several occasions and is often treated as a spectac#lar event.
,here are t$o dimensions of recovery from a persistent vegetative stateB recovery of conscio#sness and
recovery of f#nction. 8ecovery of conscio#sness can %e verified %y relia%le evidence of a$areness of self and
the environment, consistent vol#ntary %ehavioral responses to vis#al and a#ditory stim#li, and interaction $ith
others. 8ecovery of f#nction is characteri@ed %y comm#nication, the a%ility to learn and to perform adaptive
tasks, mo%ility, self-care, and participation in recreational or vocational activities. 8ecovery of conscio#sness
may occ#r $itho#t f#nctional recovery, %#t f#nctional recovery cannot occ#r $itho#t recovery of conscio#sness
'"sh$al, 1;;*.
Possi#le treatment and cres
6#rrently no treatment for vegetative state e7ists that $o#ld satisfy the efficacy criteria of evidence-%ased
medicine. )everal methods have %een proposed $hich can ro#ghly %e s#%divided into fo#r categoriesB
pharmacological methods, s#rgery, physical therapy, and vario#s stim#lation techniA#es. Pharmacological
therapy mainly #ses activating s#%stances s#ch as tricyclic antidepressants or methylphenidate. 2i7ed res#lts
have %een reported #sing dopaminergic dr#gs s#ch as amantadine and %romocriptine and stim#lants s#ch as
de7troamphetamine.
>33?
)#rgical methods s#ch as deep %rain stim#lation are #sed less freA#ently d#e to the
invasiveness of the proced#res. )tim#lation techniA#es incl#de sensory stim#lation, sensory reg#lation, m#sic
and m#sicokinetic therapy, social-tactile interaction, etc. :elo$ are some details related to treatments that have
demonstrated some hope.
$olpidem
,here is c#rrently limited evidence that the imida@opyridine hypnotic dr#g @olpidem ')tilno7D"m%ien* can
have positive %ehavioral effects in some people $ith P().
>3?
"s of yet, fe$ scientific st#dies have %een
p#%lished on the effectiveness and the res#lts have %een sometimes contradictory.
>3!?>30?
Levodopa
&n addition, there have %een several case st#dies analy@ed that emphasi@e another pharmacological possi%ility
of treatment for patients in a persistent vegetative state. ,hree patients $hose %rains had %een damaged %y
severe head in.#ry recovered from a persistent vegetative state after the administration of a dr#g called
levodopa, $hich %oosts the %ody+s dopamine levels. &n all three cases, the patients $ere deeply comatose on
arrival to the hospital, remained #nresponsive to simple ver%al commands, and their condition $as #nchanged
for a lengthy period of time even after intensive treatment incl#ding s#rgery. "ll three patients $ere diagnosed
as %eing in a persistent vegetative state for three, seven, and t$elve months respectively '2ats#da et al., 3003*.
6ase 1 descri%es a 1 year old %oy $ho, three months after his tra#ma, co#ld not follo$ moving o%.ects $ith
his eyes and e7perienced tremor-like invol#ntary movements as $ell as hypertonicity 'increased tension of the
m#scles, meaning the m#scle tone is a%normally rigid, hampering proper movement*. 4evodopa $as
recommended to relieve the patientLs parkinsonian feat#res. )#rprisingly, after nine days of treatment the
patientLs invol#ntary movements $ere red#ced and he %egan to respond to$ard voices. ,hree months after
treatment, he $as a%le to $alk and o%tained the intelligence of an elementary school child. Ene year after his
tra#ma, he $as a%le to $alk to high school %y himself. 6ase 3 involves a yo#ng ad#lt $ho #nder$ent deep
%rain stim#lation one year after the tra#ma and sho$ed no improvement. 4evodopa $as administered and one
year later, once his t#%es $ere removed, he said, F& $ant to eat s#shi and drink %eerMF 6ase 3 descri%es a
middle-aged man $ho e7perienced spasticity of his e7tremities, $as administered levodopa, and $as a%le to
say his name and address correctly after only t$o months. "fter ne#rological eval#ation, all three cases
revealed asymmetrical rigidity or tremor and presynaptic damage in the dopaminergic '#ses dopamine as
ne#rotransmitter* systems. &n concl#sion, levodopa sho#ld %e considered for patients in a persistent vegetative
state $ith atypical feat#res in their lim%s and $ho have 28& evidence of lesions in the dopaminergic path$ay,
partic#larly presynaptic lesions in areas s#ch as the s#%stantia nigra or ventral tegment#m. Data sho$s that only
0J of ad#lt patients recover after %eing in a vegetative state for si7 to t$elve months. ,his poor recovery rate
demonstrates the significance in the rapid recovery of patients that %egin levodopa treatment, partic#larly in
those $ho $ere in a vegetative state for almost a year.
%aclofen
,his #ne7pected and late recovery of conscio#sness raises an interesting hypothesis of possi%le effects of
partially regained spinal cord o#tp#ts on reactivation of cognition. Ether case st#dies have sho$n that recovery
of conscio#sness $ith persistent severe disa%ility 1; months after a non-tra#matic %rain in.#ry $as at least in
part triggered and maintained %y intrathecal %aclofen administration ')arN 2 et al., 3007*.
"emoval of cold int#ated o!ygen
"nother doc#mented case reports recovery of a small n#m%er of patients follo$ing the removal of assisted
respiration $ith cold o7ygen. ,he researchers fo#nd that in many n#rsing homes and hospitals #nheated o7ygen
is given to non-responsive patients via tracheal int#%ation. ,his %ypasses the $arming of the #pper respiratory
tract and ca#ses a chilling of aortic %lood and chilling of the %rain. ,he researchers descri%e a small n#m%er of
cases in $hich removal of the chilled o7ygen $as follo$ed %y recovery from the P() and recommend either
$arming of o7ygen $ith a heated ne%#li@er or removal of the assisted o7ygen if it is no longer needed. ,he
a#thors f#rther recommend additional research to determine if this chilling effect may either delay recovery or
even may contri%#te to %rain damage.
>37?
%ifocal e!tradral cortical stimlation
&n Decem%er 3008, Dr )ergio 6anavero, Director of the "dvanced =e#romod#lation Cro#p %ased in ,#rin,
&taly and one of the leading e7perts in the field of cortical stim#lation, anno#nced that a girl 'Creta* in the
permanent vegetative state 'i.e. vegetative state lasting more than 13 months*, recovered conscio#sness and $as
regraded as minimally conscio#s follo$ing several months of bifocal extradural cortical stimulation '6anavero
et al. 300;*, a minimally invasive ne#ros#rgical techniA#e he and others developed for the treatment of central
pain, Parkinson+s disease, stroke reha%ilitation, depression, and other ne#rologic and psychiatric disorders
'6anavero 300;*. )im#ltaneo#s stim#lation of the fronto-parietal Fconscio#snessF net$ork achieved a marked
improvement of the defa#lt net$ork of the %rain. " meas#re of vol#ntary responsiveness has %een o%tained.
Previo#s attempts at deep %rain stim#lation - ,erri )chiavo %eing one of the patients - failed to restore
conscio#sness. ,his kind of stim#lation can also %e g#ided %y res#lts of ,ranscranial 2agnetic )tim#lation
',2)* as this $as a%le to transitorily improve a patient in P() 'Dr Pape, 6hicago 300;
>38?
* and another in the
minimally conscio#s state '3010*.
&pidemiology
&n the /nited )tates, it is estimated that there may %e %et$een 1!,000I0,000 patients $ho are in a persistent
vegetative state, %#t d#e to poor n#rsing home records e7act fig#res are hard to determine.
>3;?
&thics and policy
"n ongoing de%ate e7ists as to ho$ m#ch care, if any, patients in a persistent vegetative state sho#ld receive in
health systems plag#ed %y limited reso#rces. &n a case %efore the =e$ Gersey )#perior 6o#rt, :etanco#rt v.
,rinitas, a comm#nity hospital so#ght a r#ling that dialysis and 6P8 for s#ch a patient constit#tes f#tile care.
"n "merican %ioethicist, Gaco% 2. "ppel, arg#ed that any money spent treating P() patients $o#ld %e %etter
spent on other patients $ith a higher likelihood of recovery.
>30?
,he patient died nat#rally prior to a decision in
the case, res#lting in the co#rt finding the iss#e moot.
&n 3010, :ritish and :elgian reported in an article in the =e$ <ngland Go#rnal of 2edicine that some patients
in persistent vegetative states act#ally had eno#gh conscio#sness to Fans$erF yes or no A#estions on f28&
scans.
>31?
5o$ever, it is #nclear $hether the fact that portions of the patients+ %rains light #p on f28& $ill help
these patient ass#me their o$n medical decision making.
>31?
Professor Ceraint 8ees, Director of the &nstit#te of
6ognitive =e#roscience at /niversity 6ollege 4ondon, responded to the st#dy %y o%serving that, F"s a
clinician, it $o#ld %e important to satisfy oneself that the individ#al that yo# are comm#nicating $ith is
competent to make those decisions. "t the moment it is premat#re to concl#de that the individ#al a%le to ans$er
! o#t of 0 yesDno A#estions is f#lly conscio#s like yo# or &.F
>31?
&n contrast, Gaco% 2. "ppel of the 2o#nt )inai
5ospital told the Telegraph that this development co#ld %e a $elcome step to$ard clarifying the $ishes of s#ch
patients. "ppel statedB F& see no reason $hy, if $e are tr#ly convinced s#ch patients are comm#nicating, society
sho#ld not hono#r their $ishes. &n fact, as a physician, & think a compelling case can %e made that doctors have
an ethical o%ligation to assist s#ch patients %y removing treatment. & s#spect that, if s#ch individ#als are indeed
trapped in their %odies, they may %e living in great torment and $ill reA#est to have their care terminated or
even active e#thanasia.F
>31?
'ota#le P(S patients
,ony :land
Pa#l :rophy
)#nny von :Olo$
C#stavo 6erati
=ancy 6r#@an
Cary Dockery
<l#ana <nglaro
4ia 4ee
2arlise 2#no@
5aleigh Po#tre
:ryan )to$
1aren "nn P#inlan
,erri )chiavo
"r#na )han%a#g
"riel )haron
(ice (#kov
6hayito (alde@
1ardam, Prince of ,#rnovo
,he longest doc#mented case of s#rvival in a persistent vegetative state $as <laine <sposito,
>33?
$ho remained
P() for thirty-seven years and 111 days from 1;1 to 1;78.
>33?