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PubMed1991

Tube feeding and the permanently unconscious: the Supreme Court's decision in Cruzan.

In the recent case of Cruzan v. Director, Missouri Department of Health, a majority of the United States Supreme Court voted to affirm a Missouri decision rejecting the request of guardians for removal of tubes used to provide nutrition and hydration to a woman in a persistent vegetative state. This article analyzes the Court's decision, focusing specifically on the concurring and dissenting opinions in the case, and discusses the implications of this decision for the states.

Adult↗

PubMed1991

What does Cruzan mean to the practicing physician?

The United States Supreme Court's recent decision in the Cruzan case declared that the states have broad powers to formulate their own rules in "right to die" cases. The Court held that competent adults have a constitutionally protected "liberty interest" that allows them to accept or refuse medical treatments. Since liberty interests are subject to rational state regulation, the narrow holding in Cruzan affirmed Missouri's authority to require a "clear and convincing" evidence standard to determine a patient's wishes before life-sustaining treatment could be withdrawn from a formerly competent adult now in a persistent vegetative state. For practicing physicians, some of the implications of Cruzan are as follows: (1) For competent adult patients, physicians should respect patient wishes regarding life-sustaining treatment. (2) Physicians also should discuss with competent patients their wishes for life-sustaining treatment at a future time, when a patient may no longer be able to participate in such decisions. (3) Physicians should record these wishes in a legally acceptable instrument that addresses two aspects of care that may arise in the future if the patient becomes incompetent. What would the patient want done? Who would the patient wish to designate as a surrogate or proxy? (4) For patients who are now incompetent, but for whom decisions must be made about life-sustaining treatment, physicians should focus on the previously expressed wishes of the patient rather than on the patient's current quality of life or on the wishes of the patient's family.

Advance Directives↗

PubMed1994

Intensity of treatment in malnutrition. The ethical considerations.

Decisions about initiation and withdrawal of life-sustaining artificial nutrition and hydration are complex and sometimes are agonizing to make. Artificial feeding is considered by most medical ethicists to be a medical intervention about which decisions should be made based on the benefits, risks, and burdens of the treatment. State law varies, particularly with regard to the inclusion of artificial feeding in advance directives and in laws about its discontinuance. Conditions in which it is common for patients or families to consider refusal of artificial feeding include terminal cancer, advanced dementia, and persistent vegetative state. Alternative approaches to nutrition, such as offering favorite foods or treating underlying depression, may obviate the need for tube feeding. Competent patients may refuse any medical treatment, including life-sustaining treatment. An appropriate proxy decision maker may also refuse treatment on behalf of a mentally incapacitated patient.

Aged↗

PubMed2001

Consciousness.

Consciousness is topical, for reasons including its renewed respectability among psychologists, rapid progress in the neuroscience of perception, memory and action, advances in artificial intelligence and dissatisfaction with the dualistic separation of mind and body. Consciousness is an ambiguous term. It can refer to (i) the waking state; (ii) experience; and (iii) the possession of any mental state. Self-consciousness is equally ambiguous, with senses including (i) proneness to embarrassment in social settings; (ii) the ability to detect our own sensations and recall our recent actions; (iii) self-recognition; (iv) the awareness of awareness; and (v) self-knowledge in the broadest sense. The understanding of states of consciousness has been transformed by the delineation of their electrical correlates, of structures in brainstem and diencephalon which regulate the sleep-wake cycle, and of these structures' cellular physiology and regional pharmacology. Clinical studies have defined pathologies of wakefulness: coma, the persistent vegetative state, the 'locked-in' syndrome, akinetic mutism and brain death. Interest in the neural basis of perceptual awareness has focused on vision. Increasingly detailed neuronal correlates of real and illusory visual experience are being defined. Experiments exploiting circumstances in which visual experience changes while external stimulation is held constant are tightening the experimental link between consciousness and its neural correlates. Work on unconscious neural processes provides a complementary approach. 'Unperceived' stimuli have detectable effects on neural events and subsequent action in a range of circumstances: blindsight provides the classical example. Other areas of cognitive neuroscience also promise experimental insights into consciousness, in particular the distinctions between implicit and explicit memory and deliberate and automatic action. Overarching scientific theories of consciousness include neurobiological accounts which specify anatomical or physiological mechanisms for awareness, theories focusing on the role played by conscious processes in information processing and theories envisaging the functions of consciousness in a social context. Whether scientific observation and theory will yield a complete account of consciousness remains a live issue. Physicalism, functionalism, property dualism and dual aspect theories attempt to do justice to three central, but controversial, intuitions about experience: that it is a robust phenomenon which calls for explanation, that it is intimately related to the activity of the brain and that it has an important influence on behaviour.

Animals↗

PubMed1993

[Deep cerebral stimulation in patients with post-traumatic vegetative state. 25 cases].

In 25 cases of post traumatic vegetative state persisting 3 months after the initial injury, deep brain stimulation (DBS) has been used with the aim to activate the cortex and the hope to produce some degree of functional recovery. Electrodes were stereotaxically implanted in the centrum medianum-parafascicularis complex. Bipolar stimulation was provided daily from 8 a.m. to 8 p.m. In 12 cases no changes occurred in the clinical features and overall behaviour. DBS was given up after 2 months. All these patients with a follow-up of 1 to 10 years, remained in a permanent vegetative state, 4 of them eventually deceased. In 13 cases, following 1 to 3 weeks of DBS a definite improvement was obtained with recovery of some degree of consciousness and interpersonal relationship. However all these patients, with 1 to 12 years follow-up remained severely disabled. 2 of them deceased from intercurrent causes. The practical meaning of these clinical results are questioned. We consider that the absence of response to DBS is an important argument to predict the irreversibility of post traumatic vegetative state. It is not certain that DBS is directly responsible for positive changes observed, some degree of long-term spontaneous recovery being already documented in such patients. However it seems likely that DBS accelerates recovery and possibly improves the final level of performances.

Brain Injuries↗

PubMed1993

Donaldson v. Van de Kamp: cryonics, assisted suicide, and the challenges of medical science.

In recent years, advances in medical science have left the legal community with a wide array of social, ethical, and legal problems previously unimaginable. Historically, legislative and judicial responses to these advances lagged behind the rapid pace of such developments. The gap between the scientist's question, "Can we do it?," and the lawyer's question, "Should/may we do it?'" is most evident in the field of cryonics, with its technique of cryonic, or cryogenic, suspension. In cryonic suspension, a legally dead but biologically viable person is preserved at an extremely low temperature until advances in medical science make it possible to revive the person and implement an effective cure. The terminally ill patient who wishes to benefit from such treatment is faced with the dilemma that present life must be ceased with hope of future recovery. As a result, the process challenges our traditional notions of death and the prospects of immortality while raising a host of concomitant legal dilemmas. Some facets of this dilemma are exemplified by Donaldson v. Van de Kamp. In Donaldson, Thomas A. Donaldson sought the declaration of a constitutional right to premortem cryonic suspension of his body and the assistance of others in achieving that state. Donaldson, a forty-six-year-old mathematician and computer software scientist, suffers from a malignant brain tumor that was diagnosed by his physicians in 1988. This tumor is inoperable and continues to grow and invade his brain tissue. Donaldson's condition will gradually deteriorate into a persistent vegetative state and will ultimately result in death. Physicians predict his probable death by August 1993. Donaldson petitioned the California courts, seeking a declaration that he had a constitutional right to achieve cryonic suspension before his natural death. His doctors believe that if Donaldson waits until his natural death to be suspended, future reanimation will be futile because the tumor will have destroyed his brain. In addition, Donaldson's doctors sought an injunction against criminal prosecution for their participation in the suspension, because Donaldson, once suspended, would be considered "dead" under California law. Donaldson and his doctors built their novel argument upon the recent right-to-die cases in which the courts recognized a patient's right to have life-sustaining medical treatment withdrawn. Donaldson argued that his right to privacy and self-determination is paramount to any state interest in maintaining life. Thus, according to Donaldson, balancing the state's reasons to end--or "interrupt," as cryonics enthusiasts would have it--his own life was not necessary. The trial court dismissed the complaint for failure to state a cause of action, and Donaldson appealed to the California Court of Appeals. Because the cryonic process would necessarily involve physician-assisted death, or the aiding, advising, or encouraging of another to commit suicide, the appellate court affirmed the ruling of the trial court, holding that Donaldson did not have a constitutional right to assisted death. Additionally, in light of Donaldson's First Amendment challenge to the statute, the court upheld the criminal statute prohibiting the aiding, advising, or encouraging of another to commit suicide. This Note briefly discusses the process of cryonic suspension and explores the holding of Donaldson in light of the underlying rationale of the California right-to-die cases. Considering the contradictory state and individual interests balanced in the right-to-die cases, this Note concludes that, under a similar balancing test, premortem cryonic suspension could be permitted under certain circumstances; however, the right to premortem cryonic suspension may be more effectively recognized through legislation.

California↗

PubMed2003

Emergency craniotomy for intraparenchymal massive hematoma after embolization of supratentorial arteriovenous malformations.

OBJECTIVE: We sought to evaluate the efficacy of emergency craniotomy for patients with massive hematoma secondary to endovascular embolization of supratentorial arteriovenous malformations (AVMs) and to investigate relevant factors affecting outcome. METHODS: Within the past 15 years, 605 patients with intracranial AVMs have undergone 1066 endovascular embolizations at our institution. Of these, 24 patients experienced intracranial hemorrhage during or after the procedure. Fourteen patients were demonstrated to have massive intraparenchymal hematomas and deteriorated to a comatose state (Glasgow Come Scale score < or =6). Twelve patients underwent craniotomy within 170 minutes of being diagnosed with intraparenchymal hemorrhage. The surgical procedures performed were hematoma evacuation with total (6 patients) or partial (2 patients) resection of the AVM or hematoma evacuation only (4 patients). The clinical records of these 12 patients were analyzed retrospectively. RESULTS: Nine patients recovered to a favorable condition (good recovery, four patients; moderately disabled, five patients), one patient remained in a persistent vegetative state, and two patients died. The interval between hemorrhage and emergency craniotomy was significantly shorter in patients with favorable outcomes than in those with poor clinical outcomes. Advanced age and a larger volume of intraoperative blood loss were the factors relevant to poor outcome. Temporal lobe location of the AVM and incomplete embolization tended to correlate to poor clinical outcome, but this correlation was not statistically significant. The sizes of the AVM and the hematoma did not correlate to patient outcome. There was no difference in outcomes with regard to the surgical procedure performed. CONCLUSION: In patients with massive postembolization hematomas, emergency craniotomy should be performed as soon as possible to achieve a favorable outcome. Cooperation among interventional neuroradiologists, intensive care physicians, and neurosurgeons is essential to manage AVM patients with critical postembolization hemorrhage. There is no need to persist in performing simultaneous total resection of the AVM at the emergency craniotomy.

Adult↗

PubMed1990

Continuous recording of middle cerebral artery blood velocity in clinical neurosurgery.

Intracranial pressure, arterial blood pressure, and middle cerebral artery blood velocity were monitored for periods from 1 to 10 days in 30 neurosurgical intensive care patients. The recordings revealed rapid changes in the cerebral perfusion and gave insight into individual cerebral haemodynamic states. Twenty patients consistently showed CO2 reactivity within normal limits, between 2.5 and 5% per mm Hg (19-38% per kPa). Severely impaired CO2 reactivity, considerably below 1% per mm Hg (7.5% per kPa) was observed in four patients. Three of these patients died, while the fourth patient survived in a persistent vegetative state. Seven patients demonstrated pressure-passive blood velocity changes throughout the observed CPP range. The four patients with severely impaired CO2 reactivity all belonged to this group. The recordings from three of the remaining 23 patients showed signs of MCA blood velocity autoregulation with a lower regulatory limit of about 40-45 mm Hg. This observation is in keeping with findings from electromagnetic flowmetry on brain arteries in the neurosurgical operating field, and supports blood velocity measurements as a relevant index of brain perfusion in clinical neurosurgery and neuro-intensive care settings.

Blood Flow Velocity↗

PubMed1990

[Clinical evaluation of coma states].

Coma is difficult to define and the different gradings and scales (Glasgow, Liège) are practically used and usefull. The development of pre-hospital management and patient imaging make clinical evaluation in the acute phase of lesser importance. Brain death pose a problem for diagnostic, features (permanent loss of cerebral functions) and legal aspects. Loss of integrated neuronal functions with persistent brain stem activity will define persistent vegetative state.

Age Factors↗

PubMed1989

Improved outcome prediction based on CSF extrapolated creatine kinase BB isoenzyme activity and other risk factors in severe head injury.

The present study of 43 patients with severe head injury shows that outcome prediction can be markedly improved by combining an appropriate marker of the degree of initial brain damage and other risk factors. The patients were classified into three groups according to their actual outcome after 6 months: death (22 patients); persistent vegetative state or severe disability (eight patients); and moderate disability or good recovery (13 patients). By applying stepwise logistic discriminant analysis to the patients' data, five significant risk factors were selected: degree of neurological damage assessed by cerebrospinal fluid (CSF) extrapolated creatine kinase BB isoenzyme activity, Glasgow-Liège Coma Scale score, age, incidence of thoracic injury, and intracranial pressure (ICP). Extrapolated creatine kinase BB activity had the highest prognostic ability (67%). Uncontrollable elevated ICP proved to be systematically associated with death, whereas its absence was not necessarily indicative of a favorable outcome. The combination of the five variables yielded a total prognostic efficiency of 91%. The percentages of correctly predicted patients for the three outcome groups were, respectively, 100%, 50%, and 100%. Thus, half of the persistently vegetative and severely disabled patients were identified by the selected factors.

Adolescent↗

PubMedDate not supplied

[Diffuse axonal lesions in childhood].

OBJECTIVE: About 48% of all primary traumatic intracranial lesions are represented by so-called Diffuse Axonal Injury (DAI): a pathologic condition characterized by multiple microscopic lesions and hemorrhage at the level of midline cerebral structures, in the subcortical grey matter, and/or within the brainstem. The natural history of DAI is depressing: 100% of the patients deteriorate rapidly to coma and approximately 50% die, while 50% remain in a vegetative state or with severe neurological deficits. In the present report, we describe the results of a study aimed to evaluating the cerebral hemodynamics and the neuroradiological findings observed in four children (6, 8, 10 and 12 years old) affected by DAI. METHODS: All the patients had been admitted to the Pediatric Intensive Care Unit with Glasgow Coma Score (GCS) of 5. On admission, all patients underwent mechanical ventilation, antiedemigen and barbiturates therapy. Serial CT scan and Transcranial Doppler Sonography (TCD) examinations were carried out in all children. TCD of the middle cerebral arteries was performed through the temporal window. The children underwent insertion of a ventricular catheter for intracranial pressure monitoring. Follow-up time has been, respectively, 4 years, 3 years, 7 and 1 months. RESULTS: The Glasgow Outcome Score (GOS) of three children is 2 (persistent vegetative state), while the GOS of the one child is 3 (severe neurological deficits). CONCLUSION: DAI results in unfortunate prognosis and large health care costs. The proper medical management of this condition should be based on TCD and SjO2 and CEO2 evaluations, in order to monitor efficaciously the cerebral blood flow.

Adolescent↗

PubMed1994

Specific changes in human brain following reperfusion after cardiac arrest.

BACKGROUND AND PURPOSE: Very few reports are available on serial changes in human brain after cardiac arrest. The primary objective of this study is to investigate sequential neuroradiological changes in patients remaining in a persistent vegetative state following resuscitation after cardiac arrest. METHODS: We repeatedly studied eight vegetative patients resuscitated from unexpected out-of-hospital cardiac arrest using computed tomographic (CT) scanning and high-field magnetic resonance (MR) imaging at 1.5 T. RESULTS: In seven of the eight patients, CT scans obtained between days 2 and 6 features symmetrical low-density lesions in the bilateral caudate, lenticular, and/or thalamic nuclei. These ischemic lesions were persistently of low density on serial CT scans. In these seven patients, MR images demonstrated what were thought to be hemoglobin degradation products derived from minor hemorrhages localized in the bilateral basal ganglia, thalami, and/or substantia nigra. Diffuse brain edema in the acute stage and diffuse brain atrophy in the chronic stage were consistent neuroradiological findings. No abnormal enhanced lesions were demonstrated by CT scans. CONCLUSIONS: The most characteristic findings on high-field MR images were symmetrical lesions in the bilateral basal ganglia, thalami, and/or substantia nigra with specific changes suggestive of minor hemorrhages that were not evident on CT scans. We speculate that these minor hemorrhages result from diapedesis of red blood cells in these regions during the reperfusion period through the endothelium disrupted by ischemia-reperfusion insult.

Adult↗

PubMed2003

Morbidity and mortality after living kidney donation, 1999-2001: survey of United States transplant centers.

There have been two recent trends in living kidney donation: increased acceptance of living donors and increased acceptance of laparoscopic nephrectomy (LN). We surveyed 234 UNOS-listed kidney transplant programs to determine current living donor morbidity and mortality for open nephrectomy, hand-assisted LN, and non-hand-assisted LN. Of the 234 centers, 171 (73%) responded. Between 1/1/1999 and 7/1/2001, these centers carried out 10 828 living donor nephrectomies: 52.3% open, 20.7% hand-assisted LN, and 27% non-hand-assisted LN. Two donors (0.02%) died from surgical complications and one is in a persistent vegetative state (all after LN). Reoperation was necessary in 22 (0.4%) open, 23 (1.0%) hand-assisted LN, and 21 (0.9%) non-hand-assisted LN cases (p = 0.001). Complications not requiring reoperation were reported for 19 (0.3%) open, 22 (1.0%) hand-assisted LN, and 24 (0.8%) non-hand-assisted LN cases (p = 0.02). Readmission rate was higher for LN (1.6%) vs. open (0.6%) donors (p < 0.001), almost entirely as a result of an increase in gastrointestinal complications in LN donors. Morbidity and mortality for living donor nephrectomy at transplant centers in the United States remain low. We provide current data from which comprehensive informed consent can be obtained from donors.

Humans↗

PubMed1993

Persons and death: what's metaphysically wrong with our current statutory definition of death?

This paper challenges the recommendations of 1981 President's Commission for the Study of Ethical Problems in Medicine and Biomedical and Behavioral Research that all jurisdictions in the United States should adopt the Uniform Determination of Death Act, which endorses a whole-brain, rather than a higher-brain, definition of death. I argue that the Commission was wrong to reject the "personhood argument" for the higher-brain definition on the grounds that there is no consensus among philosophers or the general population as to what constitutes "personhood". I claim that philosophers agree that some potential for cognitive function is necessary for personhood and that, when this is absent in cases of anencephaly and persistent vegetative state (PVS), the individual should be considered dead. I further argue that the lack of consensus among the general population is due in large measure to misunderstandings about the medical reality of PVS and beliefs influenced by feelings for a specific individual in PVS. I also examine and reject two tutorist arguments which have been used to support the Commission's position: that the higher-brain definition would threaten the severely senile and severely retarded, and that there are not currently adequate medical techniques for determining when all higher-brain activities have ceased.

Adult↗

PubMed1983

Severe head injury. Clinical assessment and outcome.

A prospective study of 213 patients with severe head injury and Glasgow Coma Scores of 8 or less was conducted to identify, at 24 hours postinjury, the favorable and unfavorable clinical factors that relate to outcome one year later. According to the Glasgow Outcome Scale, 35 percent were classified Moderate Disability or Good Recovery, 13 percent were classified Severe Disability or Vegetative State, and 52 percent had died. The presence of intact brain-stem reflexes 24 hours postinjury in comatose patients with head injury is a prognostic sign for a good recovery. Favorable clinical signs include eye opening, pupillary reactivity, spontaneous eye movement, intact oculovestibular reflexes, and motor responses such as localizing. A prognosis of poor recovery is associated with nonreactive pupils, absent oculovestibular reflexes, and motor response of extension or no response at all. These negative signs, when present individually, were associated with only a 3 to 4 percent Moderate Disability or Good Recovery rate and an 85 to 91 percent mortality rate. The Glasgow Outcome Scale was also used to define recovery patterns at intervals during the first year after injury. Ninety percent of patients reached their highest outcome category by six months. The most frequent one-month outcome category for survivors was Severe Disability. By six months postinjury, 68 percent of these patients had made sufficient neurological progress to change their classification to Moderate Disability or Good Recovery. The 16 percent of patients classified at one month as in a persistently Vegetative State had a prognosis of poor outcome. Only 28 percent of these patients progressed in one year to the Severe Disability classification.

Adolescent↗

PubMedDate not supplied

Prehospital hyperventilation after brain injury: a prospective analysis of prehospital and early hospital hyperventilation of the brain-injured patient.

BACKGROUND: The Brain Trauma Foundation's Guidelines for the Management of Severe Head Injury state that the use of prophylactic hyperventilation after traumatic brain injury (TBI) should be avoided because it can compromise cerebral perfusion. The objective of this study was to assess the prevalence of unintentional hyperventilation. METHODS: A prospective evaluation of all intubated trauma patients with a diagnosis of TBI was performed. Patients with signs of impending herniation were excluded. RESULTS: Forty patients were included in the study. The average Glasgow Coma Scale (GCS) was 6.3. Of these, 28 patients (70%) were unintentionally hyperventilated. Eleven (39%) of the hyperventilated patients died or were discharged in a persistent vegetative state. Of the remaining 12 patients who experienced normal ventilation, three patients (25%) died or were discharged in a vegetative state (p = ns) (Table 1). CONCLUSION: Hyperventilation was common after TBI. However, patients ventilated to a normal PaCO2 were significantly more acidotic. Prehospital personnel should undergo educational training after development of strict ventilation protocols for patients suffering TBI.

Adult↗

PubMed1999

Brain death.

Current law in the United States authorizes physicians to diagnose brain death by applying generally accepted neurologic criteria for determining loss of function of the entire brain. This article offers a medical-legal perspective on problems that may arise with respect to the determination of brain death. These include the possibility of diagnostic error, conceptual disagreements that may constrain the use of neurologic criteria to diagnose death, and the conflation of brain death and loss of consciousness. This article also addresses legal aspects of the debate over whether to expand the definition of brain death to include permanent unconsciousness. Although existing laws draw a clear distinction between brain death and the persistent vegetative state, many courts have authorized removal of life support from individuals whose unconsciousness is believed to be permanent on proof that removal accords with preferences expressed before sentience was lost.

Adult↗

PubMed2001

[Causes of dementia and bed-ridden state in elderly victims of road traffic accidents in Japan].

BACKGROUND: In Japan, autopsies are seldom performed for the victims of road traffic accidents (RTA). Thus, when an elderly RTA victim dies after long-term hospitalization, the actual cause of death is hard to determine. SUBJECTS: Eight hundred eleven road traffic victims (69 +/- 16 years, M/F = 592/219) for whom insurance companies required us to judge the medical causal relation between the accident and the death from the view point of clinical forensic medicine. METHODS: We discussed and reevaluated the cause of death and decided the cause and effect relation based on medical information. RESULTS: The number of subjects was equivalent to 8.4% of the yearly deaths by RTA in the investigated area, 19.3% of the aged death by RTA. An autopsy was performed only for 5%, ISS was 17.0 +/- 11.5; 94% were hospitalized; 62% continued to be unconscious, involving dementia (32%), persistent vegetative state (17%), coma or semi-coma (13%). Of the cases investigated, 89% died after becoming bedridden, which in 87% of cases was due to the RTA. The odds ratios of a bedridden state for head AIS > = 3, lower limbs AIS > = 2, lower limbs AIS > = 3, spinal AIS > = 3, chest AIS > = 2 were 3.1, 3.2, 7.2, 2.5, 1.8, respectively. The odds ratios of dementia for head AIS > = 3, head AIS > = 4, chest AIS > = 4 were 29.2, 35.9, 1.2, respectively. Patients with head injuries were more likely to be bedridden and senile, and patients with leg fractures tended to be bedridden, particular in the aged. When elderly traffic victims became bedridden or senile, most of them, 399 bedridden victims and 53 non-bedridden victims, died within 242 +/- 283 days, and 356 +/- 284 days from the RTA, respectively. The cause of death could be classified into five categories; pneumonia, other infection, malnutrition and/or dehydration, malnutrition and/or dehydration with pneumonia, malnutrition and/or dehydration with other infection. Traffic deaths were recorded on 31% of death certificates, but were 77% by our reevaluation (p < 0.00001), because the cause-of-death can be difficult to determine in elderly traffic victims. Logistic regression was used to calculate the risk of dementia caused by bone fractures after adjusting for age and gender. The risk of dementia due to bone fractures was influenced by the number of the long fractured bones, a high age group, a lower ADL, and a past history of dementia. Thus, we speculate that traumatic dementia based on bone fractures may occur.

Accidents, Traffic↗