What if those coma patients thought to be beyond help could actually hear what we are saying? Could feel when pushed and prodded? Could respond to doctors, if only they could see the signs? A new group of neuroscientists thinks it has proved we can communicate with these “locked-in” patients – though not everyone believes them
On the face of it, the decision by a High Court judge in the case of M is no surprise - few would have expected a ruling to allow a patient with any level of consciousness and feeling to die. But a closer inspection of the 76-page judgement shows that Mr Justice Baker did not find his decision a straightforward one.
A Canadian man who was believed to have been in a vegetative state for more than a decade, has been able to tell scientists that he is not in any pain. It's the first time an uncommunicative, severely brain-injured patient has been able to give answers clinically relevant to their care. Scott Routley, 39, was asked questions while having his brain activity scanned in an fMRI machine. His doctor says the discovery means medical textbooks will need rewriting. Vegetative patients emerge from a coma into a condition where they have periods awake, with their eyes open, but have no perception of themselves or the outside world.
Scientists have been able to reach into the mind of a brain-damaged man and communicate with his thoughts. The research, carried out in the UK and Belgium, involved a new brain scanning method. Awareness was detected in three other patients previously diagnosed as being in a vegetative state. The study in the New England Journal of Medicine shows that scans can detect signs of awareness in patients thought to be closed off from the world. Patients in a vegetative state are awake, not in a coma, but have no awareness because of severe brain damage. The scientists used functional magnetic resonance imaging (fMRI) which shows brain activity in real time.
Brain imaging has allowed a man who was previously considered unconscious to answer a series of yes-or-no questions. The study, published this week in the New England Journal of Medicine1, challenges clinicians' definition of consciousness and provides an unprecedented opportunity to communicate with those who show no outward signs of awareness.
Breakthrough could lead to improvements in treatment of brain-damaged patients who cannot move or speak A crash victim thought to have been in a vegetative state for more than a decade has used the power of thought to tell scientists he is not in pain.
We aim to improve the medical care and understanding of disorders of consciousness following an acute insult such as coma, vegetative state, minimally conscious state or locked-in syndrome. Coma Science Group Cyclotron Research Center & Neurology Dept University of Liège
Background The differential diagnosis of disorders of consciousness is challenging. The rate of misdiagnosis is approximately 40%, and new methods are required to complement bedside testing, particularly if the patient's capacity to show behavioral signs of awareness is diminished. Conclusions These results show that a small proportion of patients in a vegetative or minimally conscious state have brain activation reflecting some awareness and cognition. Careful clinical examination will result in reclassification of the state of consciousness in some of these patients. This technique may be useful in establishing basic communication with patients who appear to be unresponsive.
The Neuromedia Corner aims to share news and stimulate an effective dialogue about the state of the art of neuroscience technologies, their risks and benefits and the associated ethical and social issues. The Neuromedia Corner is an idea of the bid - Brains in Dialogue project.
National clinical guidelines on the care of people in a vegetative or minimally conscious state, following severe brain injury These long-awaited guidelines will be a major contribution to clinical and ethical standards of care for this group of patients, not only in the UK but internationally. For England and Wales, they provide much needed clarity on legal decision-making. You can buy a print copy of the guidelines (130 pp, £15) from our online shop, or download a free PDF below. The guidelines were developed by a panel of experts in the field, who have organised complicated and wide-ranging information into six coherent sections: 1 Defining criteria and terminology 2 Assessment, diagnosis and monitoring 3 Acute to longer-term management 4 Ethical and medico-legal issues 5 End-of-life issues 6 Service organisation and commissioning Each section is followed by a set of clear recommendations.
Clinical criteria for PVS will clearly need to be revised in the light of this information. However, this research does not answer deep ethical questions about what should be done. These patients have profound brain injuries and their lives are extremely restricted. How will we evaluate their desires? What should we do if they wish to die? We will still need to do the ethical work to evaluate the implications of what they want, particularly whether they wish to live or die. This is one step towards an answer to the question of how we should care for people with severe brain injuries, but it is not the solution. Not only do we need to know what they want, we also need to know how limited medical resources should be fairly distributed and what constitutes a rational desire to die.
The Supreme Court of Canada heard the case of Toronto patient Hassan Rasouli Monday, which centres on the complex and often deeply painful issue of who should decide end-of-life care. With an aging demographic, increased life expectancy and ever more sophisticated technological interventions, these kinds of cases will almost certainly become more frequent. This is a welcome chance for the country’s highest court to clarify how end-of-life treatment should proceed when a physician and a patient’s family disagree.
In this article, I consider whether the advance directive of a person in minimally conscious state ought to be adhered to when its prescriptions conflict with her current wishes. I argue that an advance directive can have moral significance after its issuer has succumbed to minimally conscious state. I also defend the view that the patient can still have a significant degree of autonomy. Consequently, I conclude that her advance directive ought not to be applied. Then I briefly assess whether considerations pertaining to respecting the patient's autonomy could still require obedience to the desire expressed in her advance directive and arrive at a negative answer.