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Results for “Persistent Vegetative State”

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PubMed1995

Recommendations for use of uniform nomenclature pertinent to patients with severe alterations in consciousness. American Congress of Rehabilitation Medicine.

There continues to be considerable confusion and controversy on the use of diagnostic and clinical terms assigned to patients with severe alterations in consciousness. This confusion results largely from the lack of a uniform classification system that is based on behaviorally defined criteria. This position paper provides recommendations for defining coma, vegetative state (including persistent and permanent vegetative state), akinetic mutism, the minimally responsive state, and locked-in syndrome based on neurobehavioral and neuropathologic features. Current controversies surrounding use of these terms also are discussed.

Akinetic Mutism↗

PubMed2006

Literature review, case report, and expert discussion of prolonged refractory status epilepticus.

We report the case of a 30-year-old woman with severe, prolonged refractory status epilepticus requiring more than 6 months of iatrogenic coma. Opinions on prognosis and clinical management were solicited from a number of experienced neurointensivists and epileptologists at multiple time-points during the clinical course. The ensuing discussion, annotated with references, is presented here. Several experts commented on isolated cases of young patients with encephalitis requiring up to 2-3 months of iatrogenic coma, yet still having good outcomes. Treatments discussed include ketamine, gammaglobulin, plasmapheresis, steroids, adrenocorticotropic hormone, very high-dose phenobarbital, isoflurane, lidocaine, electroconvulsive therapy, ketogenic diet, hypothermia, magnesium, transcranial magnetic stimulation, vagus nerve stimulation, deep brain stimulation, and neurosurgery. The patient eventually suffered a cardiac arrest but was resuscitated as requested by the family. Seizures then stopped, and the patient has remained in a persistent vegetative state since.

Adult↗

PubMedDate not supplied

Considerations for the use of assistive technology in patients with impaired states of consciousness.

While there is limited literature addressing the application of assistive technology in patients in persistent vegetative state (PVS) and minimally conscious state (MCS), it is believed that it can assist with the assessment, diagnosis and treatment as well as management of these patients. The use of technology to assist in PVS and MCS is mostly limited to the application of simple binary switch devices to determine whether a motor response is consistent or otherwise. However, the application of such technology is often undermined due to a lack of established protocols for use by the multidisciplinary team (MDT), as well as a lack of available technical resources. Therefore the ongoing development of assessment instruments as well as effective outcome measures used by an MDT is imperative. This article aims to discuss some key aspects to consider in the use of assistive technology when assessing and treating people in impaired conscious states. Possible considerations and suggestions will be discussed through this paper and a case study will be used to demonstrate some of these interventions.

Adult↗

PubMed2003

[Diagnosis of vegetative state as a basis for medical treatment on the borderline between life and death].

The term 'vegetative state' is most appropriate for the state which develops when patients open their eyes after a comatose phase, without regaining consciousness. The definition and the diagnostic criteria from the Multi Society Task Force on Persistent Vegetative State are usable for the clinical practice in the Netherlands. The vegetative state must be differentiated from coma, locked-in syndrome and minimally conscious state. A systematic, multidisciplinary approach under the direction of a physician is key to diagnosing vegetative state. To this end, a clinical assessment is recommended with reassessment and verification of the diagnosis at appropriate moments. Careful observation remains the fundamental to the diagnosis.

Coma↗

PubMed2005

Assessing decision-making and capacity in minimally-aware patients.

The assessment of decision-making by minimally-aware patients represents an important challenge for medicine, science and the law. This paper seeks to assist the dialogue between these disciplines by discussing three aspects: the difficulties inherent in establishing a reliable means of communication with the patient; the difficulty of exploring understanding and decision-making once a means of communication has been determined; and the legal implications including problems that may arise with the 'balance of probabilities' legal standard of proof. These aspects are discussed using the example of patients who have very severe acquired brain damage or are in states which verge on the 'persistent vegetative state'. The discussion is informed by existing case law and by reference to clinical method and scientific theory including binomial theory.

Decision Making↗

PubMed1989

[Persistent alpha-vegetative state].

After briefly reviewing the concepts of "coma" and "alpha-coma", we report the case of a patient with presumable Pick's disease who spent several weeks in a vegetative state with a normal and reactive EEG in the alpha range in the later stages of her illness. We (a) emphasize some implications of the appearance of the eyes in such patients, b) stress the importance of distinguishing alpha activity from true alpha rhythm and (c) suggest the category "alpha-coma" should include only those individuals bearing evidence of disorders of the junctional tegmentum of the pons and midbrain. In a complementary way, we propose that patients in a persistent vegetative state displaying normal EEG should be separately classified as persistent "alpha-vegetative state".

Alpha Rhythm↗

PubMed2001

Knight v. Beverly Health Care Center: in the Supreme Court of Alabama.

HELD: Before tube feeding may be withdrawn from a person who is unconscious, pursuant to the directives of a living will, there must be a finding by clear and convincing evidence that the patient is in a "persistent vegetative state" as defined in her living will, or in a "permanent unconscious state" as defined by state statute.

Advance Directive Adherence↗

PubMed2004

The vegetative and minimally conscious states: consensus-based criteria for establishing diagnosis and prognosis.

Disorders of consciousness continue to be the subject of hot debate in healthcare settings, research consortiums, bioethics departments and media forums. There are no standards of care to guide assessment and treatment decisions resulting in wide disparities in daily practice. In response to this problem, expert panels in neurology and neurorehabilitation were convened and charged with developing consensus-based definitions and diagnostic criteria for disorders of consciousness. The Multi-Society Task Force Report on the persistent vegetative state and the Aspen Workgroup statement on the minimally conscious state represent two such initiatives. This paper summarizes the practice recommendations proposed by these groups and discusses their implications for existing and future interventions.

Humans↗

PubMed2005

Clinical diagnosis of prolonged states of impaired consciousness in adults.

A prolonged state of impaired consciousness is a devastating consequence of severe structural brain injury but fortunately is uncommon. Patients may be diagnosed as being in a persistent vegetative state, having akinetic mutism, or being in a minimally conscious state. These conditions can be distinguished from each other by a comprehensive clinical neurologic examination. Recovery is determined by age, cause, and time in such state. For patients diagnosed as being in a permanent (irreversible) vegetative state, hope for a clinically meaningful recovery is unrealistic after 1 year. Prolonged survival is possible only with meticulous care and aggressive medical intervention to prevent and treat systemic complications.

Adult↗

PubMed2006

The impact of Roman Catholic moral theology on end-of-life care under the Texas Advance Directives Act.

This essay reviews the Roman Catholic moral tradition surrounding treatments at the end of life together with the challenges presented to that tradition by the Texas Advance Directives Act. The impact on Catholic health care facilities and physicians, and the way in which the moral tradition should be applied under this statute, particularly with reference to the provision dealing with conflicts over end-of-life treatments, will be critically assessed. I will argue, based on the traditional treatment of end-of-life issues, that Catholic physicians and institutions should appeal to the conflict resolution process of the Advance Directives Act only under a limited number of circumstances. The implications, under the Texas statute, of varied interpretations of Pope John Paul II's recent allocution on artificial feeding and hydration in the persistent vegetative state will also be considered.

Advance Directives↗

PubMed2006

Stopping nutrition and hydration technologies: a conflict between traditional Catholic ethics and church authority.

This article focuses on the troubling effects of the secular values of individual freedom and autonomy and their impact on laws regarding suicide and euthanasia. The author argues that in an increasingly secularized culture, death and dying are losing their meaning and are not thought of within a moral framework. The debate regarding the provision of artificial nutrition and hydration is critically considered in light of the history of Catholic morality as well as within the modern healthcare context, and finally with new insight from the recent statements made by the late pope. Drane argues that the pope's insistence on providing artificial nutrition and hydration despite irreversible persistent vegetative states in unconvincing.

Alzheimer Disease↗

PubMed2005

States of severely altered consciousness: clinical characteristics, medical complications and functional outcome after rehabilitation.

OBJECTIVE: To identify and characterize demographics, injury variables, complications, and functional outcomes in Asian patients presenting in States of Severely Altered Consciousness (SSAC). DESIGN: Descriptive case series review. SETTING/SUBJECTS: Acute rehabilitation unit with intensive, comprehensive neurological rehabilitation program. Thirty consecutive patients diagnosed to be in persistent vegetative state (PVS) or minimally conscious (MCS) state over a 4-year period were included. MAIN OUTCOME MEASURES: Disability Rating Scale (DRS), Ranchos Los Amigos Scale (RLAS), Modified Barthel Index (MBI). RESULTS: Seventeen (57%) were male, with a mean age of 31.8 years (median 25y, range 15-74, SD 16.3y). Twenty-one (70%) had traumatic brain injury, and median GCS on acute admission was 5. The mean length of stays (LOS) in acute and rehabilitation facilities was 90.1 days and 106.3 days respectively. Tracheostomized patients had longer acute LOS. (p = 0.03). All patients had improvement in their DRS scores upon rehabilitation discharge. The MBI was insensitive in identifying low-level changes; though paired analyses were significant for improvement. Seventeen (57%) patients were in PVS and the rest in MCS on admission to rehabilitation. Twelve patients progressed to a state of awareness, with eye responses as the most frequent first sign. There was a greater spread of higher RLAS categories on rehabilitation discharge. Urinary tract infection (16 patients, 53%) was the most common medical complication. Nineteen (63%) had central fever and this group was more functionally disabled (p = 0.045). The mean number of medications on discharge was 6. The majority of patients (22 patients, 73%) were discharged home, and patients continued to make functional progress post-discharge. CONCLUSIONS: Despite SSAC states, the majority improve, however profound disability persists. Possible predictors of a worse outcome include tracheostomy, severity of initial disability, initial RLAS II level and presence of central fever.

Adolescent↗

PubMed1995

Acute subdural hematoma following disseminated intravascular coagulation associated with an obstetric catastrophe.

The clinical, laboratory, radiological and operative recordings of a patient with disseminated intravascular coagulation (DIC) related to therapeutic abortion is reported. During a comatose state following respiratory arrest, anisocoria with right dilated unreactive pupil and decerebration signs appeared. A brain CT scan showed a right frontotemporal hemorrhage. On surgical intervention a subdural hematoma was found and removed. The patient remained in a persistent vegetative state. The rarity of subdural hematoma complicating DIC is presented and the causes of intracranial bleeding in obstetrics are reviewed.

Abortion, Therapeutic↗

PubMed1997

Efficacy and risk of ventricular drainage in cases of grade V subarachnoid hemorrhage.

We retrospectively evaluated efficacy and risk of external ventricular drainage which was performed in early management of high grade subarachnoid hemorrhage. Acute ventricular drainage was performed on 36.6% of 93 patients with grade V subarachnoid hemorrhage. The percentage of patients whose GCS improved following ventricular drainage were 14.3% from GCS 3, 61.5% from GCS 4, 42.9% from GCS 5 and 42.9% from GCS 6. The occurrence rate of rebleeding was approximately three-fold higher in patients who underwent ventricular drainage than in patients who did not. Aneurysmal surgery performed after ventricular drainage, compared with acute aneurysmal surgery, resulted in the smaller percentage of patients who became persistently vegetative and in the larger percentage of patients who became severely disabled, while it did not change the percentage of patients who resulted in favorable outcome and death. These results of retrospective study suggested that ventricular drainage performed on grade V subarachnoid hemorrhage increased the risk of rebleeding and did not increase the percentage of patients who resulted in favorable outcome although it reduced the percentage of patients who resulted in persistent vegetative state.

Adult↗

PubMed1995

Regional cerebral metabolism of glucose in comatose and vegetative state patients.

Regional cerebral metabolism of glucose (rCMRglu) was evaluated in patients who were in a coma and vegetative state to determine the level of brain function during these conditions. rCMRglu was measured in 17 discrete brain regions with (/-) [18F] -fluoro-2-deoxy-D-glucose (FDG) and positrn emission tomography (PET) in 15 patients with ;brain pathology subsequent to cardiorespiratory arrest (CA), head trauma (HT), or brain ischemia (BI) resulting from cerebrovascular accident or brain surgery. Five comatose patients (Coma group, n = 5), and 10 vegetative state patients (VS, patients awake but not aware) were studied. The VA patients were subdivided, according to the length of their VS condition, into a VS group (n = 6, < 3 months if CA or BI patients, or < 12 months if HT patients) and a persistent vegetative state group (PVS, n = 4, > 3 months if CA or BI patients of > 12 months if HT patients.) Ten normal age-matched subjects served as control. Global CMRglu was 6.72 +/- 0.93 (+/-SD) mg/100 g/min in control subjects. It was significantly (p < - 0.001) reduced to 3.70 +/- 61 in coma, to 3.45 +/- in VS, and to 2.33 +/- 0.34 mg/100 g/min in PVS patients. rCMRglu was significantly reduced (p < - 01001) from control values in all the 17 structures surveyed in every patient. In the Coma and VS groups, there was an overlapping of rCMRglu in the majority of the brain structures. (ABSTRACT TRUNCATED AT 250 WORDS)

Adolescent↗

PubMed2006

Long-term neurological complications after hypoxic-ischemic encephalopathy.

Hypoxic-ischemic encephalopathy accompanying cardiac arrest is a common cause of long-term neurological dysfunction. With the improvement in prehospital emergency systems, larger numbers of people are resuscitated from cardiac arrests, although with the increased prospect of neurological sequelae. Neurological impairment after cardiac arrest is dependent on the degree of brain damage suffered during the arrest. Although the duration and severity of brain ischemia is often difficult to determine, clinicians are often faced with difficult issues related to predicting outcome related to awakening and long-term neurological deficits after the arrest. Neurological impairments range from mild cognitive deficits to severe motor and cognitive deficits that preclude independence in many activities of daily living. Several neurological syndromes have been described in patients who awaken from hypoxic-ischemic coma with lasting motor and cognitive deficits. This review will address many of the common syndromes after hypoxic-ischemic encephalopathy, including persistent vegetative states, seizures, myoclonus, movement disorders, cognitive dysfunction, and other neurological abnormalities.

Brain↗

PubMed2006

Electrophysiological prognostication and brain injury from cardiac arrest.

Anoxic coma after cardiorespiratory arrest warrants precocious investigation to establish probable outcome. Electroencephalogram (EEG) may uncover subclinical seizures; EEG grades have provided accurate prognosis of poor and favorable outcomes, but are weakest in those patients in between. Somatosensory evoked potentials now have proven benefit in accurately establishing a poor outcome (death or persistent vegetative state) when cortical responses (N20) are absent. These studies are particularly helpful when clinical examination of coma, early on, might yield uncertain prognosis (i.e., when brain stem reflexes are present). Combining clinical examination with electrophysiology has increasingly yielded multimodality approaches to early prognostication of coma after cardiorespiratory arrest, with more recent studies using event-related and middle-latency potentials showing promise for distinguishing good outcome (to consciousness), from awake but vegetative states. Further studies are warranted for this multimodality approach which, hopefully, may yield more widespread practical use of these testing modalities.

Brain↗

PubMed1999

Commentary: legal and ethical aspects of sperm retrieval.

Author argues that the adequacy of "reasonably inferred consent" as a justification for the retrieval of sperm posthumously or after persistent vegetative state suffers from definitional ambiguity, faulty comparisons, and ultimately may justify practices that are not in the interest of survivors or children yet to be conceived.

Brain Death↗