Pulling The Plug Too Soon?




Power Plug

A new report raises important questions about whether or not some people diagnosed as irrevocably unconscious really are.

The study published in The New England Journal of Medicine (NEJM) finds that some patients previously diagnosed to be in a vegetative state were mentally aware and able to communicate. Researchers found that when such patients were placed in an functional MRI (fMRI) scanner and asked questions, they exhibited measurable brain activity showing actual understanding and response.

This means that fMRI can be used as a communication tool linking some patients who are unable to physically respond to those around them.

This new technique of determining consciousness and communication, when fully realized, has serious legal and ethical implications. It may make a significant difference in the way in which decisions are made to continue or withhold treatment in cases involving a diagnosis of a vegetative state. Currently, decisions to continue or deny treatment to non-responsive patients are made by doctors and surrogates who often act on the authority of documents known as advanced directives or “living wills” which, according to current practice and law, have evolved to permit the withdrawal of care and treatment, including nutrition and hydration. Usually, these decisions depend upon a finding that the individual is in a permanent persistent vegetative state where no communication is possible, and that the patient cannot comprehend their condition and express an opinion. Now it appears that the current practices used to determine the presence of consciousness and withdrawal of treatment may be inadequate. The findings of the new study show that, even when no physical movement or observable response to stimuli are present, means exist to permit some individuals to respond sufficiently to prove that they understand their condition and may wish to continue treatment.

The gravity of this finding is underscored by the level of uncertainty that already exists in such cases. The New England Journal article references other sources showing that even before the use of fMRI as used in the study, cases of persistent vegetative states and other related disorders were already improperly diagnosed 40% of the time. How many of these cases end in termination of treatment when the patient is actually conscious and capable of assisted communication?

This information is sobering to me as an attorney who prepares health care directives. I find that in the usual course of an estate planning review, it is difficult to have clients focus on the issue of health care. Now, the question arises concerning my responsibility to inform my clients of the fMRI option and whether or not to require a test before a decision is made to withdraw treatment.

In my experience in estate planning, clients customarily spend little time pondering the Advanced Medical Directive and its’ consequences.  When I bring up the topic, the usual response is a quick and dismissive “just pull the plug.” Their presumption of medical certainty made such a decision simple.

Now, I anticipate the discussions will be longer and more tentative.

References

Monti, M., Vanhaudenhuyse, A., Coleman, M., Boly, M., Pickard, J., Tshibanda, L., Owen, A., & Laureys, S. (2010). Willful Modulation of Brain Activity in Disorders of Consciousness New England Journal of Medicine, 362 (7), 579-589 DOI: 10.1056/NEJMoa0905370

Andrews K, Murphy L, Munday R, & Littlewood C (1996). Misdiagnosis of the vegetative state: retrospective study in a rehabilitation unit. BMJ (Clinical research ed.), 313 (7048), 13-6 PMID: 8664760

  • Maria Pomeroy

    My sister was diagnosed with persistent vegetative state a year ago as a result of a car crash. My mom kept feeding and taking care of her at home. After seven months she woke up and now she is recuperating. She is not just conscious but with all her brain functions intact. She is speaking not only in Spanish but also in English. She is aware of everything and the doctors that are now attending her are gladly surprise at how well she is doing. This article had answered many questions I had about the competency of the Doctors and the nagging question “if the brain was dead how now after seven months it recovered all its functions?”

    • http://slakhan.gnif.org Shaheen E Lakhan, MS, MEd, PhD, MD

      Dear Maria,

      Thanks for your sharing your story. As we strive to better classify “brain death” and “vegetative states” using modern imaging (including fMRI for specialized neural activity and ultrasound for intracerebral circulation), cases like yours only remind us that we still have a journey ahead of us to better diagnose and prognosticate neurological outcomes. Congratulations to your sister and your family.

      Sincerely,
      Shaheen

    • Thomas Cochrane

      “if the brain was dead how now after seven months it recovered all its functions?”

      You mentioned that your sister was in a vegetative state, not brain dead. The prognosis for a young patient in VS after trauma is poor, but it doesn’t become certain until about 12 months.

      So there’s not much surprising in the story…I’m glad things turned out well.

  • Martin Wixson

    Having worked with families who have faced this issue, I can’t help but wonder how many were misdiagnosed or prematurely “written off” as vegetative and made the decision to pull the plug. It will be interesting to see what the medical profession will do with this new fMRI technology as it pertains to the diagnosis and treatment of severe brain injury. Good article.

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  • http://www.linkedin.com/in/donaldclary1 Donald Clary

    An excellent and thought provoking article. Coincidentially,
    I also reviewed a posting today from a “certified nurse legal consultant,” a registered RN who (among other things) assists family members in making these types of decisions. It appears that greater thought is being directed to these questons.

  • Thomas Cochrane

    The study is intriguing, but it doesn’t link the fMRI findings to prognosis, which is the most important factor that goes into a decision to ‘pull the plug.’

    Look at it this way: if you were in VS and knew you’d be stuck there permanently (the prognosis bit), you either would or wouldn’t want to pull the plug. Now if you’re misdiagnosed as being in VS and knew you’d be stuck there permanently (the prognosis bit), would you be more or less interested in pulling the plug?

    Until the prognosis bit is tied to this new test, it’s clinically unhelpful, and has basically no implications for decisionmaking in the cognitively devastated patient.

Ronald Clary, JD

Ronald Clary, JD, is an attorney with a private practice in Canoga Park, California. He is a graduate of the University of California Los Angeles Law School (JD). He is currently also on the staff of Biola University, La Mirada, California.
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