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PubMed1997

The persistent vegetative state and anencephaly: problematic paradigms for discussing futility and rationing.

Medical futility has been a controversial issue for the last several years. Although anencephalic infants and patients in the persistent vegetative state (PVS) have often been suggested as paradigmatic cases for discussing the issue of medical futility, there is no consensus among physicians or ethicists that treatment of such patients is futile and courts have not supported the futility argument. Focusing on the issue of medical futility will not resolve the management issues surrounding the care of patients in PVS or anencephalic infants. Instead, an analysis of the benefits and burdens of treatments offers a potential solution by demonstrating that the real problem is the dissociation of the benefits and burdens of treatment for such patients. We propose the idea that anencephalic infants and patients in PVS provide an appropriate paradigm for discussing the issue of rationing of health-care resources.

Anencephaly↗
PubMed2002

Acetazolamide vasoreactivity in vascular dementia and persistent vegetative state evaluated by transcranial harmonic perfusion imaging and Doppler sonography.

To clarify the pathophysiological differences of the cerebrovascular reserve capacity in relation to cerebral cognitive impairments between vascular dementia (VaD) and persistent vegetative state (PVS), we evaluated acetazolamide (ACZ) vasoreactivity testing by transcranial harmonic perfusion imaging (HPI) and Doppler sonography (TCD). Sixteen patients (age: 29-85 years; mean: 62) were divided into three groups: 7 VaD, 4 PVS, and 5 nondementia patients. Mean velocity (Vm) in the middle and posterior cerebral artery (MCA, PCA) was measured, and time-intensity curves of the HPI were evaluated at three regions of interest-the bilateral temporal lobe (TL), basal ganglia (BG), and thalamus (Th). TCD and HPI were evaluated before (resting state) and after ACZ administration, and vasoreactivity was compared among the three groups in terms of resting values and relative changes (%Delta) of Vm, peak intensity (PI), area under curve (AUC), and mean transit time (MTT). Results of the resting state: Decreased Vm, PI, and AUC of the VaD and PVS groups were more obvious in the right side. Results of vasoreactivity: In the PVS group, %DeltaVm decreased in the left PCA and MCA; %DeltaPI and %DeltaAUC decreased in the left TL and bilateral BG. In the VaD group, %DeltaPI and %DeltaAUC decreased in the right TL; %DeltaMTT tended to increase in the left side. ACZ vasoreactivity tests by transcranial HPI and TCD allowed bedside, noninvasive quantitative evaluation of the pathophysiology of cognitive function impairment in relation to cerebrovascular reserve capacity in VaD and PVS.

Acetazolamide↗
PubMedDate not supplied

[Ethical questions in the treatment of the person in persistent vegetative state. The symbolic case of Nancy Beth Cruzan].

The article deals with a the ethical issues about treatment of Persistent Vegetative State (Pvs) patients. The Nancy Beth Cruzan case, the US woman who died after the withdrawal of tube feeding and hydration after seven years of Pvs is analysed as paradigmatic case. The ethical analysis face with the following issues: 1. Is the Pvs synonymous of cerebral death?; 2. How the tube feeding and hydration must be considered: ordinary or extraordinary, proportionate or disproportionate means? 3. The issue of the living will; 4. the economic impact of the management of the Pvs patients. The conclusion of the contribution is the following: the withdrawal of the artificial feeding and hydration of a Pvs patient must be considered as omissive euthanasia, and consequently it is an action ethically unacceptable, in the light of the Hippocratic medical tradition and of the person-centred ethics.

Adult↗
PubMed1985

Persistent vegetative state. Review and report of electrodiagnostic studies in eight cases.

Of 81 comatose patients studied for two years, eight entered the persistent vegetative state (PVS), of whom four died and four survived. Clinically, all eight showed characteristic findings of wakefulness without cognitive function. Electrodiagnostic studies were characterized by (1) electroencephalograms that showed a range of patterns that were unchanged from the comatose through the vegetative state, (2) normal brainstem auditory evoked responses, (3) median somatosensory evoked responses that showed prolonged central conduction time, and (4) diminishing amplitude of the N20 response. These features may serve for identifying and monitoring patients in the PVS with a view to accurately predicting outcome.

Adult↗
PubMed1988

[Clinicophysiological study of multimodality evoked potentials and computed tomographic findings in persistent vegetative state].

The auditory brainstem response (ABR), short latency somatosensory evoked potential (SSEP) and visual evoked potential (VEP) of patients in the persistent vegetative state (PVS) are reported, and the correlations between the electrophysiological findings and the CT scan findings with the three clinical grades of the PVS (transitional, incomplete and complete vegetative syndromes) are discussed. Twenty two patients in a vegetative state caused by subarachnoid hemorrhage (3), hypertensive intracerebral hemorrhage (5), cerebral infarction (6), head injury (3), cerebral anoxia (4) and brain tumor (1). Each evoked response was evaluated for the presence or absence of abnormalities and assigned a grade ranked I to III. Briefly an evoked response was assigned a grade I, II, III if it satisfied the respective criteria of normal, moderately abnormal and severely abnormal or absent electrical activity. On the other hand CT scan findings in the PVS were evaluated for abnormal low density areas, ventricular dilatation and enlargement of the sulci and cisterns indicative of atrophy of the brain parenchyma. SSEP and VEP were better correlated with the clinical grade than ABR, and upper brainstem atrophy and abnormal low density area in CT scan findings were more valuable as an index to expresses the clinical features than ventricular dilatation. On the basis of these results, it is concluded that studies of ABR, SSEP and VEP associated with CT scan findings in the PVS could be a useful diagnostic aid to evaluate the lesions of these patients.

Adult↗
PubMed1993

Ethics consultants' recommendations for life-prolonging treatment of patients in a persistent vegetative state.

OBJECTIVE--Surprisingly little is known about the content of ethics consultants' recommendations. We chose to study this issue using hypothetical persistent vegetative state (PVS) cases. We addressed four questions: What recommendations do ethics consultants give regarding life-prolonging treatment (LPT) in PVS cases? To what degree is there consensus? What factors influence recommendations? Do recommendations conform to established guidelines? DESIGN--Questionnaire survey. Our questionnaire asked subjects what they would recommend for seven hypothetical vignettes involving a PVS patient that varied with respect to advance directives and family wishes. We also questioned subjects about demographic characteristics, ethics consultation experience, and personal preference for LPT in PVS. SUBJECTS--Attendees at an annual meeting of the Society for Bioethics Consultation (n = 154). RESULTS--The response rate was 77%. Eighty-one percent of respondents were ethics committee members and 62% were ethics consultants. There was general agreement among respondents for only one of seven vignettes: in the case of a PVS patient whose advance directive and family agree that LPT be stopped, 93% recommended stopping all LPT. Responses to other vignettes varied considerably. Although patient wishes were an important factor influencing recommendations, none of the respondents adhered invariably to the patient's advance directive. Recommendations were also influenced by family wishes, resource allocation considerations, legal constraints, and personal preference for LPT in PVS. Guidelines we examined were generally too equivocal to be useful for evaluating ethics consultants' recommendations. CONCLUSIONS--The finding of wide variability in ethics consultants' recommendations suggests a need to clarify standards for ethics consultation.

Coma↗
PubMed1994

Issues for nurses who care for patients in persistent vegetative states.

In a series of interviews, personal stress was identified as the most significant problem for neuroscience nurses who care for patients in persistent vegetative states. Other issues included inconsistent medical care, demanding physical care requirements, quality-of-life, ordinary versus extraordinary treatments, and the impact of this condition on patients' families. Some recommendations are presented that should help to alleviate some of these concerns.

Attitude of Health Personnel↗
PubMedDate not supplied

Persistent vegetative state: which sensory-motor variables should the physiotherapist measure?

This study used a modified Delphi technique to establish a list of core items which should be included in the measurement, by the physical therapist, of sensory-motor capacities of persons in a persistent vegetative state. Twenty-eight physical therapists with a mean of 5.9 years of experience working with this clientele participated in the study and identified 105 items as being important in the evaluation of the PVS patient (Round I). The study planning committee reduced these to 20 categories and asked the therapists to rate each category of items (a 5-point scale) as to it's importance (Round II). Physiotherapists identified 14 variables as being 'extremely' or 'very important' to include in such an evaluation. These included: tonus, voluntary movement on request, postural reactions, passive range of motion, tolerance to verticalization and postural status. These results are being used to develop a quantitative assessment instrument to be used by the physical therapist working with the PVS patient.

Arousal↗
PubMedDate not supplied

[Persistent vegetative state. Paradigm of current discussion on alterations of consciousness].

INTRODUCTION: The vegetative state is the current paradigm of discussions about the alterations of conscience. DEVELOPMENT: Although accepted by most investigators, it is still controversial. The dilemma starts with the denomination itself. In this paper we propose the denomination persistent vegetative state . We start with a historical review of the integration of consciousness. We also give epidemiological data and point out the clinical features, complementary tests and anatomical findings. The patients are classified into three grades for prognosis. Grade III includes those with the worst prognosis, who have no sleep waking cycles with or without opening their eyes. This section emphasises cases of prolonged survival and of late recovery who made almost complete recovery of their intellectual functions. We state that treatment is based on two aspects: treatment of the underlying disease and general measures and emphasise the need for a multidisciplinary team. From the bio ethical point of view, it should be remembered that the patients are alive and cannot be considered in the same group as the brain dead, in whom all encephalic function has been lost. CONCLUSIONS: It is not ethical to decide to suspend medical treatment when it is known that there is a possibility of recovery of the structural anatomy and function. We are morally obliged to maintain qualified medical attention. It has been shown scientifically that we not only should, but can, obtain the recovery of these patients, in spite of the serious damage suffered by their nervous system

Brain↗
PubMed1998

Evaluation of hypothalamic-pituitary-adrenocortical hormones and inflammatory cytokines in patients with persistent vegetative state.

Hypothalamic-pituitary-adrenocortical hormones, i.e. prolactin (PRL), human growth hormone (hGH), thyroid stimulating hormone (TSH), and Cortisol and plasma levels of cytokines, i.e. tumor necrosis factor-alpha (TNF-alpha), interleukin 1 beta (IL-1 beta), and interleukin-6 (IL-6), were assessed in 27 patients with persistent vegetative state (PVS) and in 16 outcome patients. In comparison with normal parameters, plasma levels of TSH were not significantly altered, while elevated basal hGH concentrations in 48.1% of PVS subjects and depressed cortisol levels in all PVS individuals and in patients who emerged from coma (outcome patients), respectively, were observed. In addition, higher TNF-alpha plasma levels in PVS subjects than in outcome patients and in healthy donors were found, while IL-1 beta plasma levels were elevated in both groups of patients in comparison with healthy controls. Of interest, in 55% PVS male patients hyperprolactinemia was observed, whereas in outcome patients more than six months these values were within normal range. In four patients, who emerged from coma in the course of this study, prolactin plasma levels were followed-up and increased basal values progressively fell to normal range within six months.

Adolescent↗
PubMed1993

Recovery of patients after four months or more in the persistent vegetative state.

A retrospective review was made of the case notes of 43 consecutive patients admitted to a unit specialising in the rehabilitation of people in the persistent vegetative state. Eleven of these patients regained awareness four months or more after suffering brain damage. The time to the first reported incidence of eye tracking was between four months and three years, and the time to the first response to command was between four and 12 months. Only one patient was eventually unable to communicate, six could use non-verbal methods of indicating at least a yes or no response, and four were able to speak. Six patients remained totally dependent while two became independent in daily activities. Four patients became independent in feeding, three required help, and four remained on gastrostomy feeding. Thus some patients can regain awareness after more than four months in a vegetative state, and, although few reach full independence, most can achieve an improved quality of life within the limitations of their disabilities. The recovery period is prolonged and may continue for several years. Even patients with profound brain damage should be offered the opportunity of a specialist rehabilitation programme.

Activities of Daily Living↗
PubMed2000

Masked intentions: the masquerade of killing thoughts used to justify dehydrating and starving people in a "persistent vegetative state" and people with other profound neurological impairments.

Denying food and water to profoundly impaired people who may not be conscious, or may only be "minimally" conscious, raises challenging ethical issues. While there is growing support for withdrawing/withholding food and water (assisted nutrition and hydration, or "AHN") from people described as being in a "persistent vegetative state" ("PVS") and people with other profound neurological impairments, such as advanced dementia, the issue remains controversial, and for many, unresolved. In this article, the author argues that if a profoundly impaired person is not imminently dying from a disease process, denying food and water causes him or her to die of dehydration and starvation. When provision of food and water does not create excessive burdens (such as extreme pain and discomfort), and if the food and water can be digested and absorbed, denying such nourishment is immoral and unethical. Under these circumstances, this denial (by commission or omission) is motivated by a real intention to cause death, whether or not that intention is explicitly recognized.

Attitude to Health↗
PubMed2000

[The care of adults in persistent vegetative state--a new challenge to nursing science?].

German scientists assume that new problems in nursing practice can be credited to an increasing number of accident-based long-term handicaps (Robert Bosch Stiftung 1996). This hypothesis is supported by epidemiological data as elaborated in the following article. Furthermore the critical examination of the terms "apallic syndrome" and "persistent vegetative state" leads up to the question which medical assumptions in relation to the phenomenon of the apallic syndrome are transferred to nursing. According to Feuser (1995) and for noted reason the medical perspective on the apallic syndrome appears to be similar to what can be observed in the practice of psychiatric care. This inheritance of medicine offers a new challenge to the nursing discipline which consequently will have to strengthen the own science.

Adult↗
PubMed1985

Persistent vegetative state. Extension of the syndrome to include chronic disorders.

Twenty-nine institutionalized patients had the vegetative state as a sequela of chronic progressive neurologic disorders. During three years, the state was persistent; none improved, ten died. Eight similar patients were reviewed retrospectively post mortem. Eight patients with severe dementia, while acutely ill or sedated, temporarily met the criteria for persistent vegetative state (PVS) but improved when the underlying condition was treated. Abnormalities on electroencephalography or computed tomographic scan are not specific for the PVS. Electroencephalograms were normal in three patients with PVS. The computed tomographic scans showed extensive destruction of the brain parenchyma but were not different from those of severely demented patients without the PVS. The PVS is a feature of the terminal phase of several progressive neurologic disorders. Patients should be treated without excessive intervention.

Coma↗
PubMed1995

The lived experience of registered nurses involved in the withdrawal of nutrition and hydration in a persistent vegetative state (PVS) patient.

The purpose of this phenomenological study was to describe the experience of five Registered Nurses involved in the withdrawal of nutrition and hydration in a persistent Vegetative State (PVS) patient. Three female and two male nurses who had been involved in the care of a PVS patient within the last ten years were interviewed. The phenomenological design was used because it provided richness and clarity to the issues raised. Three major findings were identified as positive significant experiences for these nurses: support through 'talking': coping through 'thinking'; and, decision making being kept 'in-house' (family and central care giving team).

Attitude of Health Personnel↗