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Persistent Vegetative State: It’s Not What We Thought

ve8QAd   |   October 01, 2006

A startling discovery published in the journal Nature has dramatically upset the applecart. Conventional wisdom believed that a person in a persistent vegetative state (PVS) was someone who was lying there, unresponsive, like a vegetable. We strongly disagree with the term “persistent vegetative state,” because it dehumanizes the patient. It’s very similar to how the word “fetus” is used to dehumanize the unborn child. Just as it’s easier to abort a “fetus” than an unborn child, it’s much easier to dehydrate and starve to death a body resembling a “vegetable” than it is to intentionally end the life of a loved one.

Now we have this amazing new research done at the Medical Research Council’s Cognition and Brain Sciences Unit in Cambridge, England. This has clearly shown that even though such a patient, a twenty-three-year-old woman, seemed in every way to be in a coma, nevertheless her brain was working inside of her in a way that was very similar to normal subjects. This woman had been injured more than a year earlier in a traffic accident. She had been in a deep coma and was totally unresponsive. After about five months, she had improved to where she developed a cycle of sleeping and waking and could open her eyes, but otherwise was completely unresponsive. Accordingly, she was diagnosed as in a persistent vegetative state. She joined thousands of other such patients worldwide who, after this, were simply (hopefully) given good nursing care. But her case was atypical.

These medical researchers used a brain scanning technique called functional magnetic resonance imaging (FMRI). This technique has been used on other patients but with inconclusive results, which could have been interpreted as merely reflex reactions. But this woman was different. Using the FMRI scanner, which takes magnetic snapshots of brain activity every one to two seconds, they spotted different parts of her brain lighting up, depending upon which sentence she heard.

The researcher, Dr. Adrian Owen, told her, “When you hear the word ‘tennis’, we want you to imagine being on the center court of Wimbledon playing a big rally. And every time the ball comes to you, you struggle to get it back.” Then he spoke to her, giving a different scenario. This time he said, “We want you to imagine going from room to room in your home.”

To their great surprise, she apparently understood what they were saying to her, and her brain played out those scenarios. When talking about tennis, a part of the brain, the pre-motor cortex, which governs limb movements, flickered into life. When she thought about walking around her apartment, a brain region called parahippocampal gyrus, which handles mental maps of places, lit up.

They repeated this exercise many times and sometimes fairly close together. Remarkably, after every different word, her brain lit up in these specific areas as expected. It seemed clear that she was responding to the instructions. Further, they tested brain activity on healthy volunteers and found identical reactions.

What is PVS? This term was first coined in 1972 by a Scottish neurosurgeon and an American neurologist and only came to medical attention then because of the recent advances in keeping severely damaged-brain patients alive longer than in previous years. A coma is a much deeper condition without any reflexes present. As a patient comes out of this depth, with a slight improvement on the coma, they begin to have periods of sleep and wakefulness and can open their eyes. This has been called PVS. An adult with PVS has been shown to have about a fifty percent chance of recovering within the first half year. But after one year, the chance for recovery drops dramatically. Those who do recover come out of this only partially and remain seriously disabled.

Over the years you have likely heard of cases of prolonged “unconsciousness” after which a patient has spontaneously awakened. We have known from these very exceptional cases that, at least in some cases, there has been a “locked-in” condition where the patient seemed unconscious but nevertheless was hearing and understanding things that were happening around her or him. After recovering consciousness, they were then able to describe events from memory during these periods. This has been known, but no one has been able to diagnose who was in such a locked-in state and/or who had the potential ability to recover as compared to those who could not. As a result of this, in recent years we have had cases like Terri Schiavo, who, as a result of court orders, was dehydrated and starved to death over a painful thirteen-day period.

It might be of interest to search the literature and briefly note some people who have recovered:

  • Sarah Scantlin, 18, severely injured by a drunk driver, had been in a coma-like state for twenty years. Ms. Scantlin was only able to communicate by blinking her eyes. Friends wondered if she could comprehend the world around her. Almost suddenly she began to speak, her first words being “Hi Mom.”
  • Terry Wallis, 20 and injured in a traffic accident, was paralyzed from the neck-down and could not talk. Mr. Wallis was cared for in a rehabilitation center. Then nineteen years later spoke “mom” and quickly thereafter was able to talk. His case was published in the Journal of Clinical Investigation. The researchers concluded, “We propose that axonal (brain cells) re-growth may underlie his recovery and provide its biological mechanism.”
  • Firefighter Donald Herbert had a roof collapse on him ten years ago. Without oxygen for a time, he suffered severe brain damage. Suddenly and unexpectedly he spoke, “I want to talk to my wife,” and spent the next fourteen hours conversing with her and his family.
  • A thirty-eight-year-old father of four in Rome was in a coma after an auto accident. Doctors gave Salvatore three months to live. After being “unconscious” for two years, he woke up and began to speak. He related that he remembered and understood everything going on around him during that time.
  • Eleven-year-old Haleigh Poutre was brain-injured after being badly beaten. Days later, a court ordered her life-support systems withdrawn, having made the judgment that her coma was irreversible and that there was no chance of her recovery. A legal appeal saved her life temporarily. Four months later, she became responsive and interactive and began progressive improvement.
  • Allow me to relate a personal experience. A middle-aged man, struck by lightning, was completely unresponsive. Except for immediate cardio pulmonary ventilation and life squad attention, he would have died. In the intensive care unit over the next few weeks, he remained on full cardio-pulmonary assistance. His wife visited and after some days voiced her opinion that the attending neurologist should pull the plug. She repeated this more than once. Finally on what turned out to be the second to last day, she once again asked the attending neurologist to pull the plug. He thought about it carefully and told her that they should give him at least a few more days, and he left. The attending resident then came to his bedside and in front of the patient, she pleaded with the resident to override the attending physician’s orders to pull the plug, which he declined to do. The very next day this man suddenly woke up and spoke. When his wife came to visit, he spoke to her (and I’ll never forget), “You tried to kill me. Get out of my life.” He recovered and divorced her.
  • Now we have this twenty-three-year-old British woman, brain injured one year previously, who has stunned doctors by performing mental tasks for them while showing no outward signs of awareness. This new brain scanning technique has shown that she could understand people talking to her and even mentally imagine playing tennis or walking around her apartment. When asked to perform these mental exercises by the doctors, she clearly heard and understood their words.

These Cambridge University researchers had begun testing her five months after the accident and had followed through. They state in their report, “This is extremely important. It’s the difference between life and death. From cases in Britain and the US, we know that end-of-life decisions are extremely important. This will definitely change the way we deal with these patients. When you have signs such as these of consciousness, then you cannot decide to stop food and water.” These are the words of Dr. Steven Lureys, a neurologist at the University of Liege and one of the authors of this study. The other author, Dr. Adrian Owen, stated, “These are very exciting findings. This technique may allow us to identify which patients have some level of awareness. Her decision to cooperate represents a clear act of intention which confirmed beyond any doubt that she was consciously aware of herself and her surroundings.” He noted that there were some shortcomings in the study and that other patients may not be able to hear or to understand questions being asked. “This however does give us one more tool for making these very difficult decisions.”

A new therapy?
We must concurrently report another startling finding in this area. In South Africa, a doctor gave such a patient the sleep aid drug, Ambien (Zolbidem) to quiet restlessness. Fifteen minutes later the patient woke up and then spoke with his family for several hours before the effect of the drug wore off. This same physician has now treated 150 brain-damaged patients with this drug, finding over half have improved. It’s as if “long dormant pathways in the brain are awakened,” he said.

We do know that in some cases nerve pathways in the brain can be rewired very slowly over a lengthy period of time. We have seen this particularly in children born severely handicapped. But it doesn’t happen to everyone. The big question posed by this new British research is, “Is this a method to discover those who can recover?”

No ethical physician would remove basic comfort care, such as food and fluids, to any patient, regardless if there were evidence of consciousness or not. Doctors should not play God by ending the life of those considered to be of a poor quality. The medical community cannot tolerate a repeat of the Terri Schiavo scandal. Imagine if we had this tool two years ago and the court had permitted its investigation of Terri. It’s very likely that she, as well as many other patients, would still be alive today.

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