Monday, November 12, 2007

Vegetative Patients Run Silent, Run Deep

On October 15, 2007, The New Yorker magazine published an article entitled, "Silent Minds", by Jerome Groopman, that addressed comprehensively "what scanning techniques are revealing about vegetative patients."

Such research is crucial to an understanding of the persistent vegetative state, which often invokes provisions of a "living will" or "advance care directive" document, or suggests end-of-life decisionmaking.

The article reviewed scientific research & medical investigations previously conducted in the United Kingdom, which were widely reported in September, 2006, regarding a British woman in a coma due to an auto accident.
See: EE&F Law Blog posting UK Vegetative Patient "Communicates" (09/09/06); Associated Press article, "Scan detects brain activity in vegetative patient" (09/07/06), posted by MSNBC online; and article "Vegetative Patient Shows Signs of Awareness" (09/07/07), by Benedict Carey, published by The New York Times.

The Times had reported:

A severely brain-damaged woman in an unresponsive, vegetative state showed clear signs of conscious awareness on brain imaging tests, researchers are reporting today, in a finding that could have far-reaching consequences for how unconscious patients are cared for and diagnosed.

In response to commands, the patient’s brain flared with activity, lighting the same language and planning regions that are active when healthy people hear the commands.

Previous studies had found similar activity in partly conscious patients, who occasionally respond to commands, but never before in someone who was totally unresponsive. * * *

The recent article, published a year after those reports, provides an extensive review of the British case, the professional reactions to that announcement, and similar research or treatment results in America.

The New Yorker article explores recent results from experimental treatments applied to a thirty-eight-year-old man who had suffered a head injury and had been living in a nursing home for six years before arriving at the Cleveland Clinic in 2004.

Initially, "he appeared to be minimally conscious; he occasionally mouthed single words when prompted, but he was unable to respond reliably to simple questions, or to chew and swallow."

In August, Schiff, Giacino, Joseph Fins, and Ali Rezai, a neurosurgeon at the Cleveland Clinic, along with twelve other researchers, published an article about the case in Nature.

The researchers described implanting electrodes in the man’s thalamus, which, by stimulating the brain tissue, had enabled him to regain considerable physical and mental function.

“Deep brain stimulation can promote significant late functional recovery from severe traumatic brain injury,” they wrote.

When the electrodes were turned on in the man’s thalamus, his speech improved, his movements became more fluid, and he was able to chew and swallow. When the researchers turned off the electrical stimulation, the man soon relapsed.

He is now being given regular doses of electrical stimulation and is able to speak in short sentences and to chew and swallow.

The researchers concluded that the case “challenges the existing practice of early treatment discontinuation” for minimally conscious patients who show some “interactive behaviors.” * * *

The New Yorker article is long, detailed, and comprehensive. It should be read by those interested in such issues.

The American experiences in this area appear to confirm the quote that had concluded the Times' article about the British findings, as spoken by Dr. Joseph Fins, chief of the medical ethics division of
New York Presbyterian Hospital-Weill Cornell Medical Center: “For now I think what this study does is to create another shade of gray in the understanding of gray matter.”

Update: 11/19/07:

This posting was noted recently on other blogs, including: