Physicians' attitudes about the care of patients in the persistent vegetative state: a national survey

Conscientious Objection to Aggressive Interventions for Patients in a Vegetative State

Some physicians refuse to perform life-sustaining interventions, such as tracheostomy, on patients who are very likely to remain permanently unconscious. To explain their refusal, these clinicians often invoke the language of "futility", but this can be inaccurate and can mask problematic forms of clinical power. This paper explores whether such refusals should instead be framed as conscientious objections. We contend that the refusal to provide interventions for patients very likely to remain permanently unconscious meets widely recognized ethical standards for the exercise of conscience. We conclude that conscientious objection to tracheostomy and other life-sustaining interventions on such patients can be ethical because it does not necessarily constitute a form of invidious discrimination. Furthermore, when a physician frames their refusal as conscientious objection, it makes transparent the value-laden nature of their objection and can better facilitate patient access to the requested treatment.

Prognostication in Prolonged and Chronic Disorders of Consciousness

Patients with prolonged disorders of consciousness (DOCs) longer than 28 days may continue to make significant gains and achieve functional recovery. Occasionally, this recovery trajectory may extend past 3 (for nontraumatic etiologies) and 12 months (for traumatic etiologies) into the chronic period. Prognosis is influenced by several factors including state of DOC, etiology, and demographics. There are several testing modalities that may aid prognostication under active investigation including electroencephalography, functional and anatomic magnetic resonance imaging, and event-related potentials. At this time, only one treatment (amantadine) has been routinely recommended to improve functional recovery in prolonged DOC. Given that some patients with prolonged or chronic DOC have the potential to recover both consciousness and functional status, it is important for neurologists experienced in prognostication to remain involved in their care.

The experiences of the caregivers caring for the patients in persistent vegetative state due to traumatic brain injury

Objective

Persistent vegetative state often occurs as a result of traumatic brain injuries; these patients are usually hospitalized for sustained periods, and the family caregivers are the main care providers in Iranian hospitals, especially for chronic and persistent vegetative state patients. The current study was conducted to investigate the family caregivers' experiences of caring for persistent vegetative state patients following traumatic brain injury.

Methods

This descriptive phenomenological study was carried out in 2019. Semi-structured interviews were done with 12 family caregivers caring for the patients in persistent vegetative state, hospitalized in a trauma center, after taking informed written consent and assuring about anonymity and confidentiality of their personal information. The interviews were analyzed using the Colaizzis҆ method.

Results

After analysis of 12 interviews, 5 themes, and 10 subthemes were extracted from 428 codes. Five themes include "uncountable struggles/challenges," "looking for peace," "therapeutic concerns," "preserving the connection," and "unheard sounds."

Conclusion

In this study, the family caregivers of the persistent vegetative state patients in the hospital experienced some challenges, and looked for peace by doing some work, for example, praying. They had some therapeutic concerns and unheard sounds and tried to fulfill them. We recommend, by using the results of this study and other related research, necessary care and facilities would be provided for the family caregivers of persistent vegetative state patients in hospitals.

The Baffling Babble of Brain Injury

This paper presents a dialogue that demonstrates the baffling babble of brain injury, a phenomenon that can occur when physicians' medical in formation is either exceedingly vague or delivered through terminology that can be misinterpreted by surrogates. Brain babble is distinguished from more traditional forms of miscommunication in the clinical context because of the significant degree of clinical uncertainty, existential weight, and the ability to create lose-lose decisions from which clinicians experience moral distress after providing treatments the surrogates never would have requested had they a better understanding of their loved one's neurologic injury. The paper ends with some recommendations for discussing severe brain injury with surrogates.

Worth living or worth dying? The views of the general public about allowing disabled children to die

BACKGROUND

Decisions about withdrawal of life support for infants have given rise to legal battles between physicians and parents creating intense media attention. It is unclear how we should evaluate when life is no longer worth living for an infant. Public attitudes towards treatment withdrawal and the role of parents in situations of disagreement have not previously been assessed.

METHODS

An online survey was conducted with a sample of the UK public to assess public views about the benefit of life in hypothetical cases similar to real cases heard by the UK courts (eg, Charlie Gard, Alfie Evans). We then evaluated these public views in comparison with existing ethical frameworks for decision-making.

RESULTS

One hundred and thirty participants completed the survey. The majority (94%) agreed that an infant's life may have no benefit when well-being falls below a critical level. Decisions to withdraw treatment were positively associated with the importance of use of medical resources, the infant's ability to have emotional relationships, and mental abilities. Up to 50% of participants in each case believed it was permissible to either continue or withdraw treatment.

CONCLUSION

Despite the controversy, our findings indicate that in the most severe cases, most people agree that life is not worth living for a profoundly disabled infant. Our survey found wide acceptance of at least the permissibility of withdrawal of treatment across a range of cases, though also a reluctance to overrule parents' decisions. These findings may be useful when constructing guidelines for clinical practice.

Towards the assessment of quality of life in patients with disorders of consciousness

PURPOSE

To generate foundational knowledge in the creation of a quality-of-life instrument for patients who are clinically diagnosed as being in a vegetative or minimally conscious state but are able to communicate by modulating their brain activity (i.e., behaviourally nonresponsive and covertly aware). The study aimed to identify a short list of key domains that could be used to formulate questions for an instrument that determines their self-reported quality of life.

METHODS

A novel two-pronged strategy was employed: (i) a scoping review of quality-of-life instruments created for patient populations sharing some characteristics with patients who are behaviourally nonresponsive and covertly aware was done to compile a set of potentially relevant domains of quality of life; and (ii) a three-round Delphi consensus process with a multidisciplinary panel of experts was done to determine which of the identified domains of quality of life are most important to those who are behaviourally nonresponsive and covertly aware. Five expert groups were recruited for this study including healthcare workers, neuroscientists, bioethicists, quality-of-life methodologists, and patient advocates.

RESULTS

Thirty-five individuals participated in the study with an average response rate of 95% per round. Over the three rounds, experts reached consensus on 34 of 44 domains (42 domains were identified in the scoping review and two new domains were added based on suggestions by experts). 22 domains were rated as being important for inclusion in a quality-of-life instrument and 12 domains were deemed to be of less importance. Participants agreed that domains related to physical pain, communication, and personal relationships were of primary importance. Based on subgroup analyses, there was a high degree of consistency among expert groups.

CONCLUSIONS

Quality of life should be a central patient-reported outcome in all patient populations regardless of patients' ability to communicate. It remains to be determined how covertly aware patients perceive their circumstances and quality of life after suffering a life-altering injury. Nonetheless, it is important that any further dialogue on what constitutes a life worth living should not occur without direct patient input.

Consciousness and Personhood in Medical Care

Current paradigms in Western medicine often fail to differentiate clearly between consciousness, responsiveness and personhood. The growing number of individuals who exist with sustainable cardiopulmonary systems but who are behaviorally unresponsive has prompted a cultural reconsideration of the relationship between the presence of consciousness and what it means to be a person. This article presents relevant clinical situations that exemplify the different modes in which personhood and consciousness can be associated and dissociated: disorders of consciousness, emergence from anesthesia, and neocortical death. We draw from these examples to call for a reflection on and possible revision of the dominant approach towards unresponsive persons to one in which care providers may work from the default assumption of the existence of an individual’s personhood as part of their therapeutic intervention. Behavior consistent with this assumption aligns with the principle of respect for persons in the face of the uncertainty created by the high rate of misdiagnosis of unconsciousness in unresponsive patients and is most consistent with a therapeutic approach to care considering evidence suggesting that attributing personhood may in fact evoke consciousness in these patients.

Brain death

Since the Harvard report of 1968, the concept of brain death has become widely recognized throughout the world. Most developed countries have accepted brain death as constituting death of the individual, and allow such patients to be used as ‘heart-beating’ organ donors. Although the US and most other countries accept a ‘whole-brain’ definition of brain death, the concept of brainstem death has been adopted in the UK. This article describes the UK diagnostic criteria in detail, and compares these with the criteria used in other countries. Management of the brain dead organ donor is described, and controversies relating to the concept of brain death are also discussed.

Researching patients in the vegetative state: Difficulties of studying this patient group

It is now generally accepted that all patient groups should benefit from the potential advances in knowledge and understanding that result from clinical research. Despite this principle, patients in the vegetative state remain a group that has been chronically under-researched by neuroscientists because complex ethical questions and logistical dilemmas are raised by such research.

The vegetative state is one of the best known but least understood of neurological conditions. It affects a small but significant number of people who make a poor recovery after sustaining a brain injury and has been brought to public attention through high profile cases in the UK and the USA. This paper defines the vegetative state and explores four important issues that should be considered when planning clinical research in this field. It is demonstrated that not only is it possible to undertake such research but also that there needs to be more of it so that greater numbers of patients and their families will benefit.

Attitudes toward Death Criteria and Organ Donation among Healthcare Personnel and the General Public

Objective

To examine attitudes toward death criteria and their relation to attitudes and behaviors regarding organ donation.

Data Sources

This article reviews empirical studies on the attitudes of healthcare personnel and the general public regarding death criteria and organ donation.

Study Selection and Data Extraction

The review was restricted to studies that had as a primary focus attitudes toward 1 or more of the following 3 specific criteria for determining death: (1) brain death, the irreversible loss of all functions of the entire brain; (2) higher brain death, the loss of cerebral cortex function alone; and (3) the circulatory-respiratory criteria commonly used in donation after cardiac death.

Data Synthesis

Studies consistently show that the general public and some medical personnel are inadequately familiar with the legal and medical status of brain death; attitudes toward the dead donor rule are strong predictors of willingness to donate organs using controversial criteria; concerns about donation after cardiac death surround the withdrawal of life support more than the actual death criteria used; and concerns about death criteria correlate with less favorable attitudes toward organ donation.

Conclusions

Both general and ethical education may serve to guide policy and facilitate family member requests and informed consent dialogues. Furthermore, helping families to understand and accept not only medical and legal criteria for determining death, but also ethical criteria for withdrawing life support may help them be more comfortable with their decisions.

Physicians' attitudes toward medical and ethical challenges for patients in the vegetative state: comparing Canadian and German perspectives in a vignette survey

BACKGROUND

Physicians treating patients in the vegetative state (VS) must deal with uncertainty in diagnosis and prognosis, as well as ethical issues. We examined whether physicians' attitudes toward medical and ethical challenges vary across two national medical practice settings.

METHODS

A comparative survey was conducted among German and Canadian specialty physicians, based on a case vignette about the VS. Similarities and differences of participants' attitudes toward medical and ethical challenges between the two samples were analyzed with non-parametric tests (Mann-Whitney-U-Test).

RESULTS

The overall response rate was 13.4%. Eighty percent of all participants correctly applied the diagnostic category of VS with no significant differences between countries. Many of the participants who chose the correct diagnosis of VS attributed capabilities to the patient, particularly the ability to feel pain (70%), touch (51%) and to experience hunger and thirst (35%). A large majority of participants (94%) considered the limitation of life-sustaining treatment (LST) under certain circumstances, but more Canadian participants were in favor of always limiting LST (32% vs. 12%; Chi-square: p < 0.001). Finding long-term care placement was considered more challenging by Canadian participants whereas discontinuing LST was much more challenging for German participants.

CONCLUSIONS

Differences were found between two national medical practice settings with respect to physicians' experiences and attitudes about treatment limitation about VS in spite of comparable diagnostic knowledge.

Chronic disorders of consciousness following coma: Part two: ethical, legal, and social issues

Increasing numbers of patients survive traumatic brain injury and cardiopulmonary arrest and resuscitation and are admitted to the ICU while in coma. Some of these patients become brain dead; others regain consciousness. Still others become vegetative or minimally conscious, conditions called chronic disorders of consciousness and ultimately can be cared for outside the ICU. Whether these patients would want life-sustaining therapy is difficult to determine because most have not articulated their wishes before becoming comatose. Ethics and law recognize that patients with decision-making capacity have a right to refuse such therapy and that surrogates can exercise this right for them through the principle of substituted judgment as was established by the Supreme Court of New Jersey in the case of Karen Ann Quinlan. In its decision regarding Nancy Cruzan, the US Supreme Court determined that states may require clear and convincing evidence of a vegetative patient's prior wishes before life-sustaining therapy may be withdrawn; this standard has been applied to minimally conscious patients by state supreme courts in some cases. Nevertheless, cases such as these only come to the legal system because end-of-life decisions are contested, which is unusual, and most end-of-life decisions for specific patients with chronic disorders of consciousness are made by surrogates with recommendations from physicians without court involvement. Recent advances in neuroimaging may influence both end-of-life decision-making and legal deliberations. Targeting vegetative and minimally conscious patients in medical resource allocation remains ethically unacceptable and untested in the law.

Religion and United States physicians' opinions and self-predicted practices concerning artificial nutrition and hydration

This study surveyed 1,156 practicing US physicians to examine the relationship between physicians' religious characteristics and their approaches to artificial nutrition and hydration (ANH). Forty percent of physicians believed that unless a patient is imminently dying, the patient should always receive nutrition and fluids; 75 % believed that it is ethically permissible for doctors to withdraw ANH. The least religious physicians were less likely to oppose withholding or withdrawing ANH. Compared to non-evangelical Protestant physicians, Jews and Muslims were significantly more likely to oppose withholding ANH, and Muslims were significantly more likely to oppose withdrawing ANH.

Attitudes of Lay People to Withdrawal of Treatment in Brain Damaged Patients

BACKGROUND

Whether patients in the vegetative state (VS), minimally conscious state (MCS) or the clinically related locked-in syndrome (LIS) should be kept alive is a matter of intense controversy. This study aimed to examine the moral attitudes of lay people to these questions, and the values and other factors that underlie these attitudes.

METHOD

One hundred ninety-nine US residents completed a survey using the online platform Mechanical Turk, comprising demographic questions, agreement with treatment withdrawal from each of the conditions, agreement with a series of ethical principles and three personality tests.

RESULTS

More supported treatment withdrawal from VS (40.2 % agreed, 17.6 % disagreed) than MCS (20.6 %, 41.2 %) or LIS (25.3 %, 35.8 %). Agreement with treatment withdrawal was negatively correlated with religiosity (r = -0.272, P < 0.001), though showed no significant relationship with need for cognition or empathy, and only a partial association with utilitarian judgment in a standard moral dilemma. Support for treatment withdrawal was most strongly associated with endorsement of the importance of patient autonomy, dignity, suffering, best interests. Distributive justice was not given significant weight by most. Importantly, agreement with treatment withdrawal was noticeably higher when considered from a first as opposed to third person perspective for VS (Z = -6.056, P < 0.001), MCS (Z = -6.746, P < 0.001) and LIS (Z = -6.681, P < 0.001).

CONCLUSION

Lay attitudes to withdrawal of treatment in brain damaged patients are largely shaped by values similar to those central to the secular ethical debate. Neither traditional values such as the sanctity of life nor utilitarian values relating to resource allocation seem to play a central role. Far greater weight is given to autonomy, which may explain why participants were far more willing to endorse withdrawal of treatment when the issue was presented in the first person, or in relation to a concrete case involving a patient's explicit wishes. Surveys focusing on abstract cases presented in the third person may not provide an accurate picture of lay attitudes to these critical ethical questions.

Should we provide life-sustaining treatments to patients with permanent loss of cognitive capacities?

A very troubling issue for health care systems today is that of life-sustaining treatment for patients who have permanently lost their cognitive capacities. These include patients in persistent vegetative state (PVS), or minimally conscious state (MCS), as well as a growing population of patients at the very end stage of dementia. These patients are totally dependent on life-sustaining treatments and are, actually, kept alive "artificially." This phenomenon raises doubts as to the ethics of sustaining the life of patients who have lost their consciousness and cognitive capacities, and whether there is a moral obligation to do so. The problem is that the main facts concerning the experiences and well-being of such patients and their wishes are unknown. Hence the framework of the four principles-beneficence, non-maleficence, autonomy, and justice-is not applicable in these cases; therefore we examined solidarity as another moral value to which we may resort in dealing with this dilemma. This article shows that the source of the dilemma is the social attitudes towards loss of cognitive capacities, and the perception of this state as loss of personhood. Consequently, it is suggested that the principle of solidarity-which both sets an obligation to care for the worst-off, and can be used to identify obligations that appeal to an ethos of behavior-can serve as a guiding principle for resolving the dilemma. The value of solidarity can lead society to care for these patients and not deny them basic care and life-sustaining treatment when appropriate.

Diagnostic and ethical challenges in disorders of consciousness and locked-in syndrome: a survey of German neurologists

Diagnosis and decisions on life-sustaining treatment (LST) in disorders of consciousness, such as the vegetative state (VS) and the minimally conscious state (MCS), are challenging for neurologists. The locked-in syndrome (LiS) is sometimes confounded with these disorders by less experienced physicians. We aimed to investigate (1) the application of diagnostic knowledge, (2) attitudes concerning limitations of LST, and (3) further challenging aspects in the care of patients. A vignette-based online survey with a randomized presentation of a VS, MCS, or LiS case scenario was conducted among members of the German Society for Neurology. A sample of 503 neurologists participated (response rate 16.4%). An accurate diagnosis was given by 86% of the participants. The LiS case was diagnosed more accurately (94%) than the VS case (79%) and the MCS case (87%, p < 0.001). Limiting LST for the patient was considered by 92, 91, and 84% of the participants who accurately diagnosed the VS, LiS, and MCS case (p = 0.09). Overall, most participants agreed with limiting cardiopulmonary resuscitation; a minority considered limiting artificial nutrition and hydration. Neurologists regarded the estimation of the prognosis and determination of the patients’ wishes as most challenging. The majority of German neurologists accurately applied the diagnostic categories VS, MCS, and LiS to case vignettes. Their attitudes were mostly in favor of limiting life-sustaining treatment and slightly differed for MCS as compared to VS and LiS. Attitudes toward LST strongly differed according to circumstances (e.g., patient’s will opposed treatment) and treatment measures.

Attitudes towards end-of-life issues in disorders of consciousness: a European survey

Previous European surveys showed the support of healthcare professionals for treatment withdrawal [i.e., artificial nutrition and hydration (ANH) in chronic vegetative state (VS) patients]. The recent definition of minimally conscious state (MCS), and possibly research advances (e.g., functional neuroimaging), may have lead to uncertainty regarding potential residual perception and may have influenced opinions of healthcare professionals. The aim of the study was to update the end-of-life attitudes towards VS and to determine the end-of-life attitudes towards MCS. A 16-item questionnaire related to consciousness, pain and end-of-life issues in chronic (i.e., >1 year) VS and MCS and locked-in syndrome was distributed among attendants of medical and scientific conferences around Europe (n = 59). During a lecture, the items were explained orally to the attendants who needed to provide written yes/no responses. Chi-square tests and logistic regression analyses identified differences and associations for age, European region, religiosity, profession, and gender. We here report data on items concerning end-of-life issues on chronic VS and MCS. Responses were collected from 2,475 participants. For chronic VS (>1 year), 66% of healthcare professionals agreed to withdraw treatment and 82% wished not to be kept alive (P < 0.001). For chronic MCS (>1 year), less attendants agreed to withdraw treatment (28%, P < 0.001) and wished not to be kept alive (67%, P < 0.001). MCS was considered worse than VS for the patients in 54% and for their families in 42% of the sample. Respondents' opinions were associated with geographic region and religiosity. Our data show that end-of-life opinions differ for VS as compared to MCS. The introduction of the diagnostic criteria for MCS has not substantially changed the opinions on end-of-life issues on permanent VS. Additionally, the existing legal ambiguity around MCS may have influenced the audience to draw a line between expressing preferences for self versus others, by implicitly recognizing that the latter could be a step on the slippery slope to legalize euthanasia. Given the observed individual variability, we stress the importance of advance directives and identification of proxies when discussing end-of-life issues in patients with disorders of consciousness.

The Vegetative State: Life, Death and Consciousness

The three conditions that are traditionally defined as disorders of consciousness are the comatose state, the minimally conscious state and the vegetative state. Thirty years after the phrase was coined, the definition and management of patients in vegetative states continue to provoke debate. Recent advances in neuroimaging have cast doubt on the assertion that these patients are completely unaware of their environment. This article presents a case report and review of disorders of consciousness, their definition, prognosis and ethical issues in the management of patients.

Clinical report--Forgoing medically provided nutrition and hydration in children

There is broad consensus that withholding or withdrawing medical interventions is morally permissible when requested by competent patients or, in the case of patients without decision-making capacity, when the interventions no longer confer a benefit to the patient or when the burdens associated with the interventions outweigh the benefits received. The withdrawal or withholding of measures such as attempted resuscitation, ventilators, and critical care medications is common in the terminal care of adults and children. In the case of adults, a consensus has emerged in law and ethics that the medical administration of fluid and nutrition is not fundamentally different from other medical interventions such as use of ventilators; therefore, it can be forgone or withdrawn when a competent adult or legally authorized surrogate requests withdrawal or when the intervention no longer provides a net benefit to the patient. In pediatrics, forgoing or withdrawing medically administered fluids and nutrition has been more controversial because of the inability of children to make autonomous decisions and the emotional power of feeding as a basic element of the care of children. This statement reviews the medical, ethical, and legal issues relevant to the withholding or withdrawing of medically provided fluids and nutrition in children. The American Academy of Pediatrics concludes that the withdrawal of medically administered fluids and nutrition for pediatric patients is ethically acceptable in limited circumstances. Ethics consultation is strongly recommended when particularly difficult or controversial decisions are being considered.

Different beliefs about pain perception in the vegetative and minimally conscious states: a European survey of medical and paramedical professionals

Pain management in severely brain-damaged patients constitutes a clinical and ethical stake. At the bedside, assessing the presence of pain and suffering is challenging due to both patients' physical condition and inherent limitations of clinical assessment. Neuroimaging studies support the existence of distinct cerebral responses to noxious stimulation in brain death, vegetative state, and minimally conscious state. We here provide results from a European survey on 2059 medical and paramedical professionals' beliefs on possible pain perception in patients with disorders of consciousness. To the question "Do you think that patients in a vegetative state can feel pain?," 68% of the interviewed paramedical caregivers (n=538) and 56% of medical doctors (n=1166) answered "yes" (no data on exact profession in 17% of total sample). Logistic regression analysis showed that paramedical professionals, religious caregivers, and older caregivers reported more often that vegetative patients may experience pain. Following professional background, religion was the highest predictor of caregivers' opinion: 64% of religious (n=1009; 850 Christians) versus 52% of nonreligious respondents (n=830) answered positively (missing data on religion in 11% of total sample). To the question "Do you think that patients in a minimally conscious state can feel pain?" nearly all interviewed caregivers answered "yes" (96% of the medical doctors and 97% of the paramedical caregivers). Women and religious caregivers reported more often that minimally conscious patients may experience pain. These results are discussed in terms of existing definitions of pain and suffering, the remaining uncertainty on the clinical assessment of pain as a subjective first-person experience and recent functional neuroimaging findings on nociceptive processing in disorders of consciousness. In our view, more research is needed to increase our understanding of residual sensation in vegetative and minimally conscious patients and to propose evidence-based medical guidelines for the management of possible pain perception and suffering in these vulnerable patient populations.

Magnetic resonance spectroscopy and diffusion tensor imaging in coma survivors: promises and pitfalls

The status of comatose patient is currently established on the basis of the patient-exhibited behaviors. Clinical assessment is subjective and, in 40% of patients, fails to distinguish vegetative state (VS) from minimally conscious states (MCS). The technologic advances of magnetic resonance imaging (MRI) have dramatically improved our understanding of these altered states of consciousness. The role of neuroimaging in coma survivors has increased beyond the simple evaluation of morphological abnormalities. The development of 1H-MR spectroscopy (MRS) and diffusion tensor imaging (DTI) provide opportunity to evaluate processes that cannot be approached by current morphologic MRI sequences. They offer potentially unique insights into the histopathology of VS and MCS. The MRS is a powerful noninvasive imaging technique that enables the in vivo quantification of certain chemical compound or metabolites as N-acetylaspartate (NAA), Choline (Cho), and Creatine (Cr). These biomarkers explore neuronal integrity (NAA), cell membrane turnover (Cho), and cell energetic function (Cr). DTI is an effective and proved quantitative method for evaluating tissue integrity at microscopic level. It provides information about the microstructure and the architecture of tissues, especially the white matter. Various physical parameters can be extracted from this sequence: the fractional anisotropy (FA), a marker of white matter integrity; mean diffusivity (MD); and the apparent diffusion coefficient (ADC) which can differentiate cytotoxic and vasogenic edema. The most prominent findings with MRS and DTI performed in traumatic brain-injured (TBI) patients in subacute phase are the reduction of the NAA/Cr ratio in posterior pons and the decrease of mean infratentorial and supratentorial FA except in posterior pons that enables to predict unfavorable outcome at 1 year from TBI with up to 86% sensitivity and 97% specificity. This review will focus on the interest of comatose patients MRI multimodal assessment with MRS and DTI. It will emphasize the advantages and pitfalls of these techniques in particular in predicting the coma survivors' outcome.

Media coverage of the persistent vegetative state and end-of-life decision-making

BACKGROUND

Conflicting perspectives about the diagnosis and prognosis of the persistent vegetative state (PVS) as well as end-of-life (EOL) decision-making were disseminated in the Terri Schiavo case. This study examined print media coverage of these features of the case.

METHODS

We retrieved print media coverage of the Schiavo case from the LexisNexis Academic database and used content analysis to examine headlines and text of articles describing Schiavo's neurologic condition, behavioral repertoire, prognosis, and withdrawal of life support. The accuracy of claims about PVS was assessed.

RESULTS

Our search yielded 1,141 relevant articles published (1990-2005) in the four most prolific American newspapers for this case. The most frequent headline themes featured legal (31%), EOL (25%), and political (22%) aspects of the case. Of the articles analyzed, 21% reported that Schiavo "might improve" and 7% that she "might recover." Statements explicitly denying the PVS diagnosis were found in 6% of articles. Explanations of PVS and other chronic disorders of consciousness were rare (<or=1%). Most frequently cited descriptions of behaviors were that the patient responds (10%), reacts (9%), is incapacitated (6%), smiles (5%), and laughs (5%). Withdrawal of life support was described as murder in 9% of articles.

CONCLUSIONS

Media coverage included refutations of the persistent vegetative state (PVS) diagnosis, attributed behaviors inconsistent with PVS, and used charged language to describe end of life decision-making. Strategies are needed to achieve better internal agreement within the professional community and effective communication with patient communities, families, the media, and stakeholders.

Clinical review: Prognostic value of magnetic resonance imaging in acute brain injury and coma

Progress in management of critically ill neurological patients has led to improved survival rates. However, severe residual neurological impairment, such as persistent coma, occurs in some survivors. This raises concerns about whether it is ethically appropriate to apply aggressive care routinely, which is also associated with burdensome long-term management costs. Adapting the management approach based on long-term neurological prognosis represents a major challenge to intensive care. Magnetic resonance imaging (MRI) can show brain lesions that are not visible by computed tomography, including early cytotoxic oedema after ischaemic stroke, diffuse axonal injury after traumatic brain injury and cortical laminar necrosis after cardiac arrest. Thus, MRI increases the accuracy of neurological diagnosis in critically ill patients. In addition, there is some evidence that MRI may have potential in terms of predicting outcome. Following a brief description of the sequences used, this review focuses on the prognostic value of MRI in patients with traumatic brain injury, anoxic/hypoxic encephalopathy and stroke. Finally, the roles played by the main anatomical structures involved in arousal and awareness are discussed and avenues for future research suggested.

Attitudes and behaviors of Japanese physicians concerning withholding and withdrawal of life-sustaining treatment for end-of-life patients: results from an Internet survey

BACKGROUND

Evidence concerning how Japanese physicians think and behave in specific clinical situations that involve withholding or withdrawal of medical interventions for end-of-life or frail elderly patients is yet insufficient.

METHODS

To analyze decisions and actions concerning the withholding/withdrawal of life-support care by Japanese physicians, we conducted cross-sectional web-based internet survey presenting three scenarios involving an elderly comatose patient following a severe stroke. Volunteer physicians were recruited for the survey through mailing lists and medical journals. The respondents answered questions concerning attitudes and behaviors regarding decision-making for the withholding/withdrawal of life-support care, namely, the initiation/withdrawal of tube feeding and respirator attachment.

RESULTS

Of the 304 responses analyzed, a majority felt that tube feeding should be initiated in these scenarios. Only 18% felt that a respirator should be attached when the patient had severe pneumonia and respiratory failure. Over half the respondents felt that tube feeding should not be withdrawn when the coma extended beyond 6 months. Only 11% responded that they actually withdrew tube feeding. Half the respondents perceived tube feeding in such a patient as a "life-sustaining treatment," whereas the other half disagreed. Physicians seeking clinical ethics consultation supported the withdrawal of tube feeding (OR, 6.4; 95% CI, 2.5-16.3; P < 0.001).

CONCLUSION

Physicians tend to harbor greater negative attitudes toward the withdrawal of life-support care than its withholding. On the other hand, they favor withholding invasive life-sustaining treatments such as the attachment of a respirator over less invasive and long-term treatments such as tube feeding. Discrepancies were demonstrated between attitudes and actual behaviors. Physicians may need systematic support for appropriate decision-making for end-of-life care.

Preferences of registered dietitians and nurses recommending artificial nutrition and hydration for elderly patients

OBJECTIVE

The study was designed to identify how the beliefs and perceptions of registered dietitians (RDs) affect their decisions to propose artificial nutrition and hydration (ANH) for elderly patients as compared with nurses.

DESIGN

A questionnaire consisting of demographic information, 13 belief statements, and eight patient scenarios requiring ANH was mailed to RDs (n=1,500) and nurses (n=1,500) throughout Florida. Thirteen statements, rated on a 5-point Likert scale, addressed beliefs that influence ANH decisions. Eight scenarios of patients, without an advance directive or surrogate decision maker, were created with variations in age, cognition, and emotion. For each scenario, participants selected a treatment, ANH or hydration, and responded: recommend; not recommend; undecided; or recommend a trial period; if no improvement, stop treatment.

STATISTICAL ANALYSES PERFORMED

To establish reliability and validity, the instruments were pilot-tested with a group of RDs and nurses. Cross tabulations with chi2 tests compared the distribution of responses to the belief statements and scenarios. Statistical significance was P<0.05.

RESULTS

Responses to the belief statement, "when in doubt, feed" differed significantly (P<0.001) between RDs and nurses, all other belief statements were not significantly different. In all eight scenarios, significantly more (P<0.001) RDs recommended ANH than did nurses.

CONCLUSIONS

RDs clearly endorsed feeding when in doubt; therefore, they recommended ANH more than nurses. Nurses, who hesitated to feed when in doubt, were more diverse with their recommendations, either recommending a trial or not recommending ANH. A philosophical difference related to feeding was apparent between RDs and nurses and may affect consistent and quality care in patients without an advance directive or surrogate decision maker.

Chronic disorders of consciousness

The vegetative state and the minimally conscious state are disorders of consciousness that can be acute and reversible or chronic and irreversible. Diffuse lesions of the thalami, cortical neurons, or the white-matter tracts that connect them cause the vegetative state, which is wakefulness without awareness. Functional imaging with PET and functional MRI shows activation of primary cortical areas with stimulation, but not of secondary areas or distributed neural networks that would indicate awareness. Vegetative state has a poor prognosis for recovery of awareness when present for more than a year in traumatic cases and for 3 months in non-traumatic cases. Patients in minimally conscious state are poorly responsive to stimuli, but show intermittent awareness behaviours. Indeed, findings of preliminary functional imaging studies suggest that some patients could have substantially intact awareness. The outcomes of minimally conscious state are variable. Stimulation treatments have been disappointing in vegetative state but occasionally improve minimally conscious state. Treatment decisions for patients in vegetative state or minimally conscious state should follow established ethical and legal principles and accepted practice guidelines of professional medical specialty societies.

The vegetative state and the Royal College of Physicians guidance

The Royal College of Physicians of the UK, together with the Colleges of Edinburgh and Glasgow, have produced guidance on the diagnosis and management of people in the vegetative state (report of a working party of the Royal College of Physicians, 2003). Such guidance is important when the single criterion for awareness in an individual is the perception of that awareness by a potentially fallible observer. The current guidance is reviewed and comparisons made with existing arrangements in other countries. Consideration is given to the possibility of future improvements in diagnosis with the advent of imaging and metabolic assessments of brain function and the need to define the required qualifications and training for those "experts" who are currently involved in the diagnosis of the vegetative state.

Science and society: death, unconsciousness and the brain

The concept of death has evolved as technology has progressed. This has forced medicine and society to redefine its ancient cardiorespiratory centred diagnosis to a neurocentric diagnosis of death. The apparent consensus about the definition of death has not yet appeased all controversy. Ethical, moral and religious concerns continue to surface and include a prevailing malaise about possible expansions of the definition of death to encompass the vegetative state or about the feared bias of formulating criteria so as to facilitate organ transplantation.

New and lingering controversies in pediatric end-of-life care

OBJECTIVES

Professional societies, ethics institutes, and the courts have recommended principles to guide the care of children with life-threatening conditions; however, little is known about the degree to which pediatric care providers are aware of or in agreement with these guidelines. The study's objectives were to determine the extent to which physicians and nurses in critical care, hematology/oncology, and other subspecialties are in agreement with one another and with widely published ethical recommendations regarding the withholding and withdrawing of life support, the provision of adequate analgesia, and the role of parents in end-of-life decision-making.

METHODS

Three children's hospitals and 4 general hospitals with PICUs in eastern, southwestern, and southern parts of the United States were surveyed. This population-based sample was composed of attending physicians, house officers, and nurses who cared for children (age: 1 month to 18 years) with life-threatening conditions in PICUs or in medical, surgical, or hematology/oncology units, floors, or departments. Main outcome measures included concerns of conscience, knowledge and beliefs, awareness of published guidelines, and agreement or disagreement with guidelines.

RESULTS

A total of 781 clinicians were sampled, including 209 attending physicians, 116 house officers, and 456 nurses. The overall response rate was 64%. Fifty-four percent of house officers and substantial proportions of attending physicians and nurses reported, "At times, I have acted against my conscience in providing treatment to children in my care." For example, 38% of critical care attending physicians and 25% of hematology/oncology attending physicians expressed these concerns, whereas 48% of critical care nurses and 38% of hematology/oncology nurses did so. Across specialties, approximately 20 times as many nurses, 15 times as many house officers, and 10 times as many attending physicians agreed with the statement, "Sometimes I feel we are saving children who should not be saved," as agreed with the statement, "Sometimes I feel we give up on children too soon." However, hematology/oncology attending physicians (31%) were less likely than critical care (56%) and other subspecialty (66%) attending physicians to report, "Sometimes I feel the treatments I offer children are overly burdensome." Many respondents held views that diverged widely from published recommendations. Despite a lack of awareness of key guidelines, across subspecialties the vast majority of attending physicians (range: 92-98%, depending on specialty) and nurses (range: 83-85%) rated themselves as somewhat to very knowledgeable regarding ethical issues.

CONCLUSIONS

There is a need for more hospital-based ethics education and more interdisciplinary and cross-subspecialty discussion of inherently complex and stressful pediatric end-of-life cases. Education should focus on establishing appropriate goals of care, as well as on pain management, medically supplied nutrition and hydration, and the appropriate use of paralytic agents. More research is needed on clinicians' regard for the dead-donor rule.

Outcome and ethics in severe brain damage

The patient with severe brain damage represents a considerable ethical challenge for the medical team due to uncertainties in diagnosis and prognosis, the younger age of many of these patients, and the frequent acute nature of the disease, which allows little time for discussion of end-of-life issues with the patient. Surrogates are often relied on to fill in the gaps and provide their, not always reliable, interpretation of how they feel the patient would want to have been treated. The debate regarding the withdrawing/withholding of life-sustaining treatment is discussed but may not apply to many patients with severe brain damage who do not usually require invasive life support. However, withdrawal of artificial feeding and hydration is very relevant to such patients and is highly controversial. These issues are highly emotive and subjective, and individuals' views will depend on many factors including cultural background and religion. There are relatively few published data regarding ethical issues in the severely brain damaged patient and open discussion of the multiple facets of this difficult area must be encouraged.

Increasing organ donation rates from Muslim donors: Lessons from a successful model

As the great majority of the population in Saudi Arabia is Muslim, the Islamic views about organ donation and transplantation have been the focus of interest to the transplant community in this and other Muslim countries. The first resolution of the Islamic council in Saudi Arabia (Senior Ulama Commission) about organ donation and transplantation was issued in 1982. It permitted tissue and organ transplantation from both living and cadaveric donors. This resolution marked a new era in organ transplantation in Saudi Arabia, leading to the formation of the Saudi Center of organ transplantation (SCOT), which organizes the process of organ donation and transplantation in Saudi Arabia. There were major strategies to reach the goals of the organ procurement centers adopted by SCOT: improving the awareness of the medical community to the importance of organ donation and transplantation, improving the awareness of the public at large to the importance of organ donation and transplantation, and developing an efficient coordinated system with both the donating hospitals and the transplant centers. Various organs had been transplanted in Saudi Arabia through the end of 2002: 3759 kidney transplants (1267 cadaver, 2492 living); 279 liver transplants(225 cadaver, 54 living); 92 heart transplants; 421 cornea transplants; 8 lungs; and 5 combined kidneys and pancreas. In addition, there have been many tissue donations of bone marrow, heart valves (264 hearts), skin, and bone. Despite the success of the Saudi program, there have been public and medical obstacles that have obviated the full benefit of cadaver donors. We suggest increasing the awareness of the medical community and the public at large to the importance of organ donation and transplantation.

Withdrawing life-sustaining medical treatment--a physician's personal reflection

The decision to withhold or withdraw artificially provided hydration and nutrition is one which evolves over time and must be made jointly by the medical team and the patient's family. Although withholding nutrition can be argued to be ethical and appropriate for certain clinical scenarios, it is still a decision which can be difficult to make and, because of different social and legal issues, can be difficult to carry out. This is the story of one physician's journey as he worked with the mother and father of a young child who suffered a severe neurological injury and was left in a persistent vegetative state.

Life-sustaining treatments: what do physicians want and do they express their wishes to others?

OBJECTIVES

To assess whether older physicians have discussed their preferences for medical care at the end of life with their physicians, whether they have established an advance directive, and what life-sustaining treatment they wish in the event of incapacity to make these decisions for themselves.

DESIGN

Mailed survey to a cohort of physicians.

SETTING

Physicians who were medical students at the Johns Hopkins University in graduating classes from 1946 to 1964.

PARTICIPANTS

Physicians who completed the advance directive questionnaire (mean age 68).

MEASUREMENTS

Questionnaires were sent out to known surviving physicians of the Precursors Study, an on-going study that began in 1946, asking physicians about their preferences for life-sustaining treatments.

RESULTS

Of 999 physicians who were sent the survey, 765 (77%) responded. Forty-six percent of the physicians felt that their own doctors were unaware of their treatment preferences or were not sure, and of these respondents, 59% had no intention of discussing their wishes with their doctors within the next year. In contrast, 89% thought their families were probably or definitely aware of their preferences. Sixty-four percent reported that they had established an advance directive. Compared with physicians without advance directives, physicians who established an advance directive were more likely to believe that their doctors (odds ratio (OR) = 3.42, 95% confidence interval (CI) = 2.49-4.69) or family members (OR = 9.58, 95% CI = 5.33-17.23) were aware of their preferences for end-of-life care and were more likely to refuse treatments than those without advance directives.

CONCLUSION

This survey of physicians calls attention to the gap between preferences for medical care at the end of life and expressing wishes to others through discussion and advance directives, even among physicians.

Hidden places, uncommon persons

Specialized hospital units recently created to house and maintain ventilator or other technology-dependent persons in the United States are new cultural forms that enable beings who are neither fully alive, biologically dead, nor "naturally" self-regulating, yet who are sustained by modern medical practices, to exist. These institutions both fabricate and complicate the persons who are patients there through surveillance and maintenance of their conditions. This article concerns the relationship of person to place when the consciousness of an individual, considered to be the essence of personhood in the modern Western philosophical tradition, is problematic because the person resides in a technologically produced border zone between life and death. The article explores the ways in which place and person become implicated one another: first, how consciousness and thus personhood is assessed and negotiated through the inter-subjective knowledge of hospital staff; second, how that knowledge is tied to the particular situate-dness of patients; and third, how embodiment itself-the reflexive knowledge of the-self-in-the-body-is perceived as emplaced in social and spatial relations.

Thalamic proton magnetic resonance spectroscopy in vegetative state induced by traumatic brain injury

OBJECTIVES

To determine whether proton magnetic resonance spectroscopy (MRS), a newer radiographic technology, would be useful in the evaluation of the thalamus of patients in vegetative states resulting from traumatic brain injury.

METHODS

14 victims of severe traumatic brain injury who were in the vegetative state and whose magnetic resonance images of the thalamus were normal underwent bilateral thalamic proton (MRS) studies. The N-acetyl aspartate to creatine (NAA:Cr) and choline to creatine (Cho:Cr) ratios were obtained for each patient. The proton thalamic MRS findings of patients who were in a persistent vegetative state (n = 8) and in patients who had regained awareness after being in the vegetative state (n = 6) were compared with proton thalamic MRS findings in five healthy volunteers.

RESULTS

While conventional magnetic resonance imaging suggested that each patient had a normal thalamus, proton MRS indicated that the thalamus of each patient in the series was damaged. The NAA:Cr ratio was significantly lower in the thalami of both the patients who remained in a persistent vegetative state for the duration of the study and in those who regained awareness after being in the vegetative state (p < 0.001). In addition, NAA:Cr ratios were lower in the group of patients who remained in a persistent vegetative state than in the group of patients who regained awareness after being in the vegetative state (p < 0.001).

CONCLUSIONS

Results suggest that the NAA:Cr ratio within the thalamus is significant and that thalamic MRS may be helpful when attempting to determine the degree of severity of neuronal and axonal injury in patients in the vegetative state.