Treatment Decisions for Persistive Vegitative State

Treatment Decisions for Vegetative State Patients

• Presented by Amber Comer, JD, PhD

• Affiliation: Indiana University, School of Health and Rehabilitation Sciences

What is Consciousness?

• Defined as "the state of being awake and aware of one's surroundings."

Consciousness Understanding

• Additional resource on consciousness: YouTube Video

Vegetative State vs. Minimally Conscious State

• Vegetative State:

  • Characterized by absence of responsiveness and awareness.

  • Overwhelming dysfunction of the cerebral hemispheres.

  • Retains functions in the diencephalon and brain stem, allowing autonomic functions and sleep-wake cycles.

  • May exhibit complex reflexes (e.g., eye movements, yawning) but lack awareness of self and environment.

• Minimally Conscious State:

  • Some evidence of awareness of self/environment.

  • Patients may show improvement.

  • Requires a clinical diagnosis.

  • Treatment is mainly supportive with typically bleak prognoses for persistent deficits.

Persistent Vegetative State

• Defined as irreversible vegetative condition with very small chances of regaining consciousness.

• A permanent vegetative state diagnosis requires a high degree of clinical certainty regarding irreversibility (Multi-Society Task Force on PVS, NEJM 1994).

Characteristics of Patient States

• Persistent Vegetative State:

  • No conscious awareness; life support decisions may need to be made.

• Minimally Conscious State:

  • Marked by minimal but definite behavioral evidence of self/environment awareness.

Communicating Through fMRI

• Video resource: Communicating Through fMRI

Locked-in Syndrome

• Rare neurological disorder with complete voluntary muscle paralysis, except for eye movements.

Characteristics Comparison

• Coma:

  • No eye-opening, unable to follow instructions, no communication, no purposeful movement.

• Vegetative State:

  • Return of sleep-wake cycles, may produce sounds or facial expressions without cause, unable to follow instructions or communicate.

• Minimally Conscious State:

  • Sometimes follows instructions, may communicate with gestures or speech, demonstrates emotional responses, and focuses on people or objects.

Consciousness Levels and Care Decisions

• Questions arise regarding the significance of fMRI results indicating a minimally conscious state.

• Ethical considerations on defining personhood and care decisions if consciousness is lost.

Standards of Decision Making for Patients

• Substituted Judgement vs. Best Interest

  • Ethical frameworks used to guide decision making for incapacitated patients.

History of Withholding and Withdrawing Life-Sustaining Measures

• Overview of historical cases that have influenced legal and ethical standards in life support decisions.

Case Study: Karen Ann Quinlan

• Landmark ruling regarding life-support disconnection due to persistent vegetative state, emphasizing patient's right to privacy over state interests.

  • Established paternal authority to decide in the absence of recovery prospects.

Case Study: Nancy Cruzan

• First Supreme Court case on right to die, recognizing such a right but requiring clear evidence of the patient's wishes before food and water could be withheld.

Case Study: Terri Schiavo

• Controversy over withdrawing feeding tubes, raising ethical and legal dilemmas.

Decision-Making Factors in Patient Care

• Key considerations include:

  • Allocation of healthcare resources.

  • Quality vs. quantity of life assessments.

  • Pain and suffering evaluations.

  • Prognosis attached to patients' conditions.