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Results for “Persistent Vegetative State”

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PubMed2005

Prognosis following Postanoxic Myoclonus Status epilepticus.

Prediction of outcome after cardiac arrest has important ethical and socioeconomic implications. In general, delay in recovery of neurological function is associated with a worse prognosis. The presence of myoclonic seizures early after anoxia has been identified as a poor prognostic factor. We report a series of patients who developed postanoxic myoclonus status epilepticus (MSE), which was defined as continuous myoclonic seizure activity lasting 30 min or more. The results from 18 patients were retrieved, 11 men and 7 women, age ranging from 29 to 90 years. Myoclonus developed a mean of 11.7 h after cardiac arrest, persisting for a mean of 60.5 h. Sixteen (89%) died following MSE and the 2 survivors were highly dependent or remained in a persistent vegetative state, supporting the view that prognosis is poor in this condition.

Adult↗

PubMed2006

Early morphologic and spectroscopic magnetic resonance in severe traumatic brain injuries can detect "invisible brain stem damage" and predict "vegetative states".

A precise evaluation of the brain damage in the first days of severe traumatic brain injured (TBI) patients is still uncertain despite numerous available cerebral evaluation methods and imaging. In 5-10% of severe TBI patients, clinicians remain concerned with prolonged coma and long-term marked cognitive impairment unexplained by normal morphological T2 star, flair, and diffusion magnetic resonance imaging (MRI). For this reason, we prospectively assessed the potential value of magnetic resonance spectroscopy (MRS) of the brain stem to evaluate the functionality of the consciousness areas. Forty consecutive patients with severe TBI were included. Single voxel proton MRS of the brain stem and morphological MRI of the whole brain were performed at day 17.5 +/- 6.4. Disability Rating Scale and Glasgow Outcome Scale (GOS) were evaluated at 18 months posttrauma. MRS appeared to be a reliable tool in the exploration of brainstem metabolism in TBI. Three different spectra were observed (normal, cholinergic reaction, or neuronal damage) allowing an evaluation of functional damage. MRS disturbances were not correlated with anatomical MRI lesions suggesting that the two techniques are strongly complementarity. In two GOS 2 vegetative patients with normal morphological MRI, MRS detected severe functional damage of the brainstem (NAA/Cr < 1.50) that was described as "invisible brain stem damage." MRI and MRS taken separately could not distinguish patients GOS 3 (n = 7) from GOS 1-2 (n = 11) and GOS 4-5 (n = 20). However, a principal component analysis of combined MRI and MRS data enabled a clear-cut separation between GOS 1-2, GOS 3, and GOS 4-5 patients with no overlap between groups. This study showed that combined MRI and MRS provide a reliable evaluation of patients presenting in deep coma, specially when there are insufficient MRI lesions of the consciousness pathways to explain their status. In the first few days post-trauma metabolic (brainstem spectroscopy) and morphological (T2 star and Flair) MRI studies can predict the long-term neurological outcome, especially the persistent vegetative states and minimally conscious state.

Adult↗

PubMed1995

Value theory and the best interests standard.

The idea of a patient's best interests raises issues in prudential value theory -- the study of what makes up an individual's ultimate (nonmoral) good or well-being. While this connection may strike a philosopher as obvious, the literature on the best interests standard reveals almost no engagement of recent work in value theory. There seems to be a growing sentiment among bioethicists that their work is independent of philosophical theorizing. Is this sentiment wrong in the present case? Does value theory make a significant difference in interpreting best interests? In pursuing this question, I begin with a quick sketch of broad kinds of value theories, identifying representatives that are plausible enough to count as contenders. I then explore what each account suggests in (1) neonatal treatment decisions, and (2) decisions for patients in persistent vegetative states. I conclude that while these accounts converge somewhat in their interpretations of best interests, they also have importantly different implications.

Adult↗

PubMed2004

Myoclonic status epilepticus following repeated oral ingestion of colloidal silver.

The authors report a case of a 71-year-old man who developed myoclonic status epilepticus and coma after daily ingestion of colloidal silver for 4 months resulting in high levels of silver in plasma, erythrocytes, and CSF. Despite plasmapheresis, he remained in a persistent vegetative state until his death 5.5 months later. Silver products can cause irreversible neurologic toxicity associated with poor outcome.

Adenocarcinoma↗

PubMed2004

Termination of life support after severe child abuse: the role of a guardian ad litem.

Discontinuation of life-sustaining interventions often raises ethical concerns. In cases of severe child abuse with poor prognosis for recovery, accused parents may have a conflict of interest regarding medical decision-making for their child, because the outcome of such decisions may impact legal charges filed against them. The recently issued American Academy of Pediatrics guidelines for addressing such cases recommended the appointment of a guardian ad litem for medical decision-making. We present the case of an 8-month-old infant who was abused severely by her father, resulting in a persistent vegetative state. We describe our experience with appointing a guardian ad litem and the ethical issues involved.

California↗

PubMed2003

Faith-to-faith at the bedside: theological and ethical issues in ecumenical clinical chaplaincy.

Chaplains who serve in a clinical context often minister to patients representing a wide variety of faiths. In order to offer the best pastoral care possible, the chaplain should first possess a set of personal theological convictions as a foundation for ministry. Second, he or she needs to be sensitive to the beliefs and practices of the patients. Third, it is vital to develop a relationship of acceptance and trust not only with patients under their care, but also with family members and caregivers as well. At times, situations will arise that are purely religious or theological. In a clinical setting, however, the questions and problems that arise more often are both theological and ethical. It is beneficial for the chaplain to be involved in an ethics committee, where the specifics of each case can be discussed, and staff can offer counsel to patients and their families. This study examines issues that chaplains face at the bedside, such as terminal care, life-prolonging treatments, dementia, persistent vegetative state, and euthanasia-assisted suicide. We will discover that those who are involved in clinical pastoral ministry will be called upon to be a comforter, mediator, educator, ethicist, and counselor.

Chaplaincy Service, Hospital↗

PubMed1999

In re Edna MF: case law confusion in surrogate decision making.

I review the recent case of Edna Folz, a 73 year-old woman who was suffering through the end stages of very advanced Alzheimer's dementia when her case was adjudicated by the Wisconsin Supreme Court. I consider this case as an example of how courts are increasingly misinterpreting the ethical and legal decision-making-standards known as "substituted judgment" and "best interests" and thereby threatening individuals' treatment decision-making rights as developed by other courts over the past two decades and creating serious roadblocks to health-care providers' ability to render appropriate patient care. The Wisconsin Supreme Court held that Edna's legal guardian could not authorize withdrawal of Edna's treatment, ruling that as a matter of law, if an incompetent person is not in a persistent vegetative state, it is not in his or her best interests for life-sustaining treatment to be withdrawn unless (s)he has executed an advance directive or other statement clearly indicating his or her desires.

Aged↗

PubMed1998

Prognostic factors in postraumatic severe diffuse brain injury.

UNLABELLED: It is usually defficult in clinical practice to establish factors affecting final outcome in patients suffering severe diffuse brain injury (SDBI), due to the absence of specific semiology. METHODS: We studied retrospectively 160 consecutive patients with criteria of SDBI. We performed a statistical analysis of epidemiological, clinical and radiological factors, and relationship with final outcome. RESULT: 35% of patients with severe head injury presented SDBI. Sixty percent were 15-35 year old and 73% male. More than 45% of the patients presented GCS 3 or 4. On CT performed during the first 24 h, haemorrhagic lesions appeared in white matter in 35% and subarachnoid haemorrhage was observed in 28%. During the first 24 h., 66% of patients presented values of intracranial pressure (ICP) above 20 mm Hg and a 33% below 20 mm Hg. Twenty percent of the patients had ICP > 20 mm and no response to treatment. According to the Glasgow Outcome Scale (GOS), mortality of more than 50% and 25% of patients with persistent vegetative state or severe disability were observed. CONCLUSIONS: Clinical evaluation, early CT findings, ICP values and their response to medical treatment and clinical complications were found to be related (p < 0.05) to final outcome (GOS).

Adolescent↗

PubMed2003

Acquired heterotopic ossification in the settings of cerebral anoxia and alternative therapy: two cases.

Acquired Heterotopic Ossification (HO) has been well described in the literature as a recognized complication following spinal cord injury, traumatic brain injury and joint arthroplasty. Commonly, large proximal limb joints are affected. The underlying mechanisms for ectopic bone formation remain poorly elucidated. Post-stroke hemiplegia as a cause of neurogenic HO is rare, and no published reports of HO occurring after anoxic brain injury in adults have been documented. This study reports two unusual cases of acquired HO: (1) Polyarticular HO involving the ankle joint in a 24-year-old Chinese female who suffered severe anoxic encephalopathy following near drowning which resulted in persistent vegetative state; and (2) Elbow HO in chronic post-stroke hemiplegia occurring as a complication of alternative therapy following repeated forceful manipulation by a traditional practitioner in a 46 year-old male.

Adult↗

PubMed2005

A device for the detection of cognitive brain functions in completely paralyzed or unresponsive patients.

Unresponsive patients with remaining cognitive abilities may be able to communicate with a brain-computer interface (BCI) such as the Thought Translation Device (TTD). Before initiating TTD learning, which may imply considerable effort, it is important to classify the patients' state of awareness and their remaining cognitive abilities. A tool for detection of cognitive activity (DCA) in the completely paralyzed was developed and integrated into the TTD which is a psychophysiological system for direct brain communication. In the present version, DCA entails five event-related brain-potential (ERP) experiments and investigates the capability of a patient to discriminate, e.g., between semantically related and unrelated concepts and categories. ERPs serve as an indicator of the patients' cortical information processing. Data from five severely brain-injured patients in persistent vegetative state diagnosed as unresponsive and five healthy controls are presented to illustrate the methodology. Two patients showing the highest responsiveness were selected for TTD training. The DCA integrated in the TTD allows screening of cognitive abilities and direct brain communication in the patients' home.

Adult↗

PubMed2000

The independent effect of gender on outcomes following traumatic brain injury: a preliminary investigation.

Although epidemiological studies of gender differences in outcome after brain injury are limited, studies in animals indicate higher fatality rates for females. Studies in which healthy human brain metabolism was investigated also suggest gender differences. In this paper the authors examine gender as an independent predictor of survival following brain injury. A prospective cohort of severely and moderately brain injured individuals was identified from two trauma centers over a period of 3.5 years. Patients enrolled in the cohort were followed for as long as 18 months postdischarge. The Glasgow Outcome Scale was used to measure long-term outcome. Overall, mortality was 1.28 times higher in females than males, with the greatest difference of 2.14 found in deaths postdischarge. Controlling for age, admission Glasgow Coma Score, penetrating as compared with blunt injury, and the presence of multiple trauma, females were 1.75 times more likely than males to die of their brain injury (95% confidence interval 1.09-2.82). Furthermore, females were 1.57 times more likely to experience poor outcomes (that is, severe disability or persistent vegetative state) than males. These findings suggest the need to examine similar effects in different cohorts and to identify the pathophysiological basis for the differences observed in this epidemiological study.

Adolescent↗

PubMed1991

Anticruelty care: commentary.

The anticruelty policy is a best-interests test for treatment plans including decisions to forgo life-sustaining therapy for certain incompetent patients. In connection with specific proposed therapy, the policy requires no reference to the patient's unknowable values, subjective experiences, or quality of life. The decision to undertake a treatment plan derives from the caregiver's knowledge of burdens and benefits of that treatment when used in caring for the competent or for those incompetents capable of growth or repair. The caregiver should weigh the potentially cruel effects of treatment against the likelihood of reducing suffering or encumbrance with the treatment. The terms "burden" and "benefit," in fact, are replaced by the terms "cruelty" and "beneficence," as the relevant opposing outcomes that must be weighed. Thus, the anticruelty policy shifts our scrutiny from experiences of the patient that we cannot evaluate to the proposed actions of the competent decision makers and caregivers. Notably, it is a protreatment policy when the goals of medicine are attainable; and it is an anticruelty policy when they are not. The policy does evaluate the world of the patient to the extent that it requires a judgment based upon external appearances about patient pleasure or happiness in living. It presumes to universalize larger societal values about cruelty, beneficence, compassionate concern for the helpless, and certain rights of individuals. And it presumes to universalize on the patient's behalf specific medical values about hopeless injury, timely death, the goals of medicine, and cruelty, which should remain open to societal discussion and revision. The presented definition of hopeless injury does not require brain death, coma, or persistent vegetative state. Specifically, the policy holds that death is timely for a patient with hopeless injury, and that prevention of death for such patients is not a goal of medicine but a cruelty.

Aged↗

PubMed1997

[Hospital rehabilitation of patients with severe brain injuries. II: Prognosis and effect of early intensive, specialized rehabilitation].

This article describes the prognosis of patients with severe traumatic brain injury, including patients in long-standing coma and persistent vegetative state, and presents the scientific evidence of the effect of organized, specialized, multidisciplinary, early and intensive rehabilitation of patients with severe traumatic brain injury. It is concluded that the introduction of newly developed models for the rehabilitation of patients with severe traumatic brain injury in Denmark may lead to a substantial improvement in outcome, and may also be cost efficient.

Brain Injuries↗

PubMed1995

The proof of the vegetable: a commentary on medical futility.

Patients with 'persistent vegetative state' (PVS) are often cited in the discussions of ethicists as examples of human beings who are unconscious and do not experience life, and a number of theoretical and practical recommendations have been made on that basis. This article examines the evidence and the theoretical rationale for the belief that people with PVS are unconscious and finds them wanting. This conclusion is related to the practice of the discipline of ethics.

Cognition↗

PubMed2006

Developmental order driving the relationship between executive functions and theory of mind: a case study.

Several studies have suggested there is a developmental link between executive functions and theory of mind. However, the developmental order driving the relationship is not well understood. The main reason is that the development of executive function parallels the development of theory of mind in normally developing children. In this paper, a case (H.Y.) is reported. H.Y. had lived in a persistent vegetative state for 6 years after encephalitis at the age of 10. He showed a developmental order driving the relationship between executive functions and theory of mind. These findings are consistent with recent suggestions that development of executive function might be important as a predecessor of either the ability to understand false beliefs or the ability to express that understanding.

Adult↗

PubMed1997

Causing death or allowing to die? Developments in the law.

Several cases which have been considered by the courts in recent years have highlighted the legal dilemmas facing doctors whose decisions result in the ending of a patient's life. This paper considers the case of Dr Cox, who was convicted of attempting to murder one of his patients, and explores the roles of motive, diminished responsibility and consent in cases of "mercy killing". The Cox decision is compared to that of Tony Bland and Janet Johnstone, in which the patients were in a persistent vegetative state. In all three cases, the doctors believed that their patients' quality of life was so poor that their continued existence was of no benefit to them, and decided that their lives should not be unduly prolonged, yet the doctor who was prosecuted was the one whose dying patient had requested that her death be hastened. The paper examines the law's seemingly contradictory approaches to such cases.

Double Effect Principle↗

PubMed1994

Caring for corpses or killing patients?

Care of patients in a persistent vegetative state raises serious ethical questions. Often misdiagnosed, this "new disease," which is the result of advancing medical technology, raises such serious issues as the definition of death, nurses' personal ethical and religious convictions, and the ethical integrity of the nursing profession. Conscience clauses that allow nurses to refuse to cause death in non-dying patients vary widely, but few, if any, address the situation of incompetent but non-dying patients.

Brain Death↗

PubMed2001

Early immunological defects in comatose patients after acute brain injury.

OBJECT: The aim of this prospective study was to evaluate the phagocytic, humoral, and cellular arms of the immune system in comatose patients shortly after severe brain injury and to compare the findings with those reported earlier in patients in a persistent vegetative state. The study was conducted in intensive care units and immunology laboratories of university-affiliated hospitals in central Israel. METHODS: The study group consisted of 14 men aged 16 to 65 years who were comatose as a result of acute brain injury due to mechanical trauma. All were studied within 72 hours of injury. Brain damage was severe in all cases (Glasgow Coma Scale score < 8). Healthy age- and sex-matched volunteers served as simultaneous controls. Infections arose in nine (75%) of the 12 patients in whom data were available; the cumulative mortality rate was 38% (five of 13 patients in whom outcome data were available). Every patient exhibited one or more defects in at least one arm of the immune system. Significant deficiencies were noted in neutrophil superoxide release, immunoglobulin (Ig)G, IgG1, IgM, C1q, C2, properdin, alternate C pathway, T cells, T helper cells, T suppressor cells, and natural killer cells. In an earlier series of patients examined by the authors months after the primary insult, these impairments were absent in most of the patients in the vegetative state. CONCLUSIONS: Significant deficiencies of the immune system, particularly the cellular arm, are precipitated by severe brain injury within 72 hours of the event. These impairments probably play a role in the high rate of complicating infections and multiple organ failure. Together with earlier findings, the results of this study indicate that if brain-injured patients survive these hazards, their immune system will eventually recover.

Adolescent↗