Healthcare News & Insights

Some ‘vegetative’ patients may be aware of surroundings

A new report raises significant questions about the awareness of vegetative patients — and ethical questions regarding their treatment.

The New England Journal of Medicine published a paper studying 54 patients in “persistent unconsciousness,” 23 of whom were in vegetative states. Over the course of a few years, five of the 54 were able to communicate basic information, and showed minimal brain activity in response to questions.

One such case is a 29-year-old man in Liege, Belgium. Five years ago, he survived a car accident, but ended up in a vegetative state. He remains mute, but a few months ago, he started to show traces of brain activity when spoken to.

Since then, his physicians say they have developed a communication system with him and he can confirm basic biographical information, such as family members’ names.

The process, which was developed by first testing it on healthy volunteers, works like this: The patient is told to associate a “yes” or “no” answer to a specific type of activity that can be identified on a brain scan. For example, the patient could be told to think of playing a sport for a “yes” response and being at home for “no.”

Then, doctors check the parts of the brain that process motor control or spatial recognition for activity in response to their questions. If the answers indicated by the brain function are consistently correct, it’s assumed the patient is actively communicating via conscious thought. (Note: In testing the patients, the answers are keyed to different thoughts in different sessions to ensure the responses are deliberate and voluntary.)

It’s far too early to say what the eventual prognosis is for patients who may be on the cusp of breaking out of a vegetative state. And even the researchers involved in this project admit the number of such patients who might show improvement are very small.

But the mere fact that it’s possible raises troubling ethical issues. Among them:

  • If a severely disabled patient is minimally communicative, how much can — and should — physicians consult with him or her on their treatment plan? After all, if the only response you can get is “yes” or “no,” it’s difficult to discuss the kind of nuanced information needed to get informed consent for any medical procedure.
  • Current tests to measure responsiveness (eye-tracking, MRI results, etc.) may be inadequate to diagnose some patients — but not others. Clinicians currently have no good guidelines for knowing which patients fall into which group.
  • News of patients like these can also be misinterpreted by other patients’ families as “just snapping out of it” and give them false hope for their own loved one’s prognosis.

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