Wednesday, February 09, 2005

New Signs of Awareness in Some Brain-Injured Patients

Comments from Cheryl Ford RN

"Thousands of brain-damaged people who are treated as if they are almost completely unaware may in fact hear and register what is going on around them but be unable to respond, a new brain-imaging study suggests."

This is an interesting article, but hardly enlightening since many experts in the medical profession have been trying to convince the bioethicists, pro death attorneys and family members for years, that brain injured people are aware of their surroundings. Dr. Fin's declaration of his new found enlightenment seems hollow in light of the fact that the bioethics community has been, for many years, desperately trying to establish and declare their expertise in determining when and how someone should die....primarily based on their declaration of a patient's "persistent vegetative state." Where has Dr. Fin been hiding out?

Many bioethicists, lay people with a self-proclaimed expertise in the demographics of what the American people want, and pro-euthanasia attorneys and lawmakers find this information "enlightening" because they have been voicing their opinions about a subject matter beyond the realm of their expertise. They have, likewise, resisted any attempt to extricate them from the power that they have gained through discussing these topics as if they were experts.

For years, patient advocates like Chris Borthwick, and world-reknown medical experts like William M. Hammesfahr MD, and William S. Maxfield, MD, have been adamantly teaching the danger of assuming that a neurologist or an attorney can, with a cursory bedside examination, determine whether a patient is "minimally conscious" or in a "persistent vegetative state." That is the very reason the diagnosis of PVS has a misdiagnosis rate of over 30% and many people actually recover from what this article describes as "very little chance of recovery." As Dr. Fin so poignantly states, "...they were there all the time." I wonder what the bioethics community would declare, if Terri's estranged husband manages to kill her, and they then discover, "...She was there all the time."

What this article is describing that is worth celebrating is the first indication that someday we may be able to visualize and diagnose what is known today as a "locked-in state." Here is a quote from the veritable "Bible" of the bioethicists, the 1994 Consensus Statement of the Multi-Society Task Force :

"By definition, patients in a persistent vegetative state are unaware of themselves or their environment. They are noncognitive, nonsentient, and incapable of conscious experience. There is, however, a biological limitation to the certainty of this definition, since we can only infer the presence or absence of consciousness in another person....an error might occur if a patient in a locked-in state...was wrongly judged to be unaware. Thus, it is theoretically possible that a patient who appears to be in a persistent vegetative state retains awareness but shows no evidence of it."

It would seem that this statement alone would make suspect the notion that an MRI could become a powerful tool in helping decide whether someone had lost awareness, or not. The article seems to imply a heretofore unseen measure of activity...not a lack thereof. Maybe what gives Dr. Fin "goose bumps" is the notion that one day an attorney or bioethicist can hold an MRI up to the light and say, "This person should be rehabilitated (highly unlikely) or, this person should be starved and dehydrated to death because I can see that they are totally unaware."

Using Terri as an example, Dr. Ronald Cranford, MD, an extensively credentialed leader in bioethics, viewed Terri's CT scan in 02, and declared that she had little or no cerebral cortex in her head, and it was mostly filled with cerebrospinal fluid. On the other hand, Dr. William Maxfield, MD, not a bioethicist by trade (however he does serve as a member of the ethics task force in hyperbaric medicine) but rather a world - renown specialist in radiology and nuclear medicine who assisted in the invention and development of many of the imaging techniques in use today.
He is board certified in 3 different specialties and has held faculty positions and chairmanships at the US Navy Medical School in Bethesda, Johns Hopkins Medical School, the Oschner Clinic and Foundation Hospital in New Orleans, Tulane University School of Medicine, and the LSU School of Medicine.

What was his interpretation of Terri's CT scans?

He testified that Terri has brain tissue in all the major structures of her brain. Terri's most severe damage is in her occipital region and probably her eyesight is affected the most. It is possible for her to retain memories, as she still has tissue in that part of her brain. And finally, he detects a change FOR THE BETTER between her 96 and her 2002 CT scans, which he attributes to the body's natural tendency to heal itself. Can brain tissue regenerate? YES!

Always keep in mind, once we declare a machine as the ultimate decision maker for who is alive and who isn't, we relegate our freedom of choice to the "Master Machine Interpreter." Isn't it easier to simply write down on paper whether you want to be kept alive or not, and then sign it? Make the law and the attorneys obey you and your paper rather than "consulting the MMI." Next, we will be running people through emissions testing!

It is quite obvious that Dr. Hirsch has a much more ethical and moral grasp of the significance of this wonderful research.... "The most consequential thing about this is that we have opened a door, we have found an objective voice for these patients, which tells us they have some cognitive ability in a way they cannot tell us themselves," Dr. Hirsch said. The patients are, she added, "more human than we imagined in the past, and it is unconscionable not to aggressively pursue research efforts to evaluate them and develop therapeutic techniques."


New Signs of Awareness Seen in Some Brain-Injured Patients

New York Times

February 8, 2005
By BENEDICT CAREY

housands of brain-damaged people who are treated as if they are almost completely unaware may in fact hear and register what is going on around them but be unable to respond, a new brain-imaging study suggests.

The findings, if repeated in follow-up experiments, could have sweeping implications for how to care best for these patients. Some experts said the study, which appeared yesterday in the journal Neurology, could also have consequences for legal cases in which parties dispute the mental state of an unresponsive patient.

The research showed that the brain-imaging technology, magnetic resonance imaging, can be a powerful tool to help doctors and family members determine whether a person has lost all awareness or is still somewhat mentally engaged, experts said.

"This study gave me goose bumps, because it shows this possibility of this profound isolation, that these people are there, that they've been there all along, even though we've been treating them as if they're not," said Dr. Joseph Fins, chief of the medical ethics division of New York Presbyterian Hospital-Weill Cornell Medical Center. Dr. Fins was not involved in the study but collaborates with its authors on other projects.

Other experts warned that the new research was more suggestive than conclusive, and that it did not mean that unresponsive people with brain damage were more likely to recover or that treatment was yet possible.

But they said the study did open a window on a world that has been neglected by medical inquiry. "This is an extremely important work, for that reason alone," said Dr. James Bernat, a professor of neurology at Dartmouth.

Dr. Bernat said findings from studies like these would be relevant to cases like that of Terri Schiavo, a Florida woman with brain damage who has been kept alive for years against her husband's wishes. In that case, which drew the attention of Gov. Jeb Bush and the Legislature, relatives of Ms. Schiavo disagreed about her condition, and a brain-imaging test - once it has been standardized - could help determine whether brain damage has extinguished awareness.

The patients in question have significant brain damage. Three million to six million Americans live with the consequences of serious brain injuries, neurologists said. An estimated 100,000 to 300,000 of them are in what is called a minimally conscious state: they are bedridden, cannot communicate and are unable to feed or care for themselves, but they typically breathe on their own.

They may occasionally react to instructions to blink their eyes or even reach for a glass, although such responses are unpredictable. By observing behavior in a bedside examination, neurologists can determine whether a person is minimally conscious or in a "persistent vegetative state" - without awareness, and almost certain not to recover.

In the study, a team of neuroscientists in New York, New Jersey and Washington, D.C., used imaging technology to compare brain activity in two young men determined to be minimally conscious with that of seven healthy men and women. In a measure of overall brain activity, the two groups were vastly different: the two minimally conscious men showed less than half the activity of the others.

But the researchers also recorded an audiotape for each of the nine subjects in which a relative or loved one reminisced, telling familiar stories and recalling shared experiences. In each of the brain-damaged patients, the sound of the voice prompted a pattern of brain activity similar to that of the healthy participants.

"We assumed we would get some minimal response in these patients, but nothing like this," said Dr. Nicholas Schiff, an assistant professor of neurology and neuroscience at Weill Cornell Medical College in Manhattan and the study's lead author. The two men showed near-normal patterns in the language-processing areas of their brains, Dr. Schiff said, suggesting that some neural networks "could be perfectly preserved under some conditions."

Although the number of patients studied was very small, the specificity and intricacy of the patterns made it all but impossible that the results were a fluke, said Dr. Joy Hirsch, director of the Functional MRI Research Center at Columbia University Medical Center and the study's senior author.

One of the two minimally conscious men lay still in a brain-imaging machine while his sister recounted his toast at her wedding and recalled times playing together as children. Although his eyes were closed, the researchers found that visual areas of his brain were active, suggesting that he might have been producing images, Dr. Hirsch said.

"We do not know for sure what is happening in this man's head, but if he were imagining things at the sound of his sister's voice, that would suggest some connection to emotion," Dr. Hirsch said.

Since the study was completed, Dr. Hirsch said, the team has run the same kinds of tests on seven similar brain-injury patients, with similar results: the language processing networks in their brains display seemingly normal patterns upon their hearing the voice of a loved one. The government has provided financing for the team to conduct a larger study of mental activity in minimally conscious people.

A better understanding of brain patterns in minimally conscious patients should also help cut down on misdiagnosis by doctors, Dr. Fins said. He said one study had found that as many as 30 percent of patients identified as being unaware, in a persistently vegetative state, were not. They were minimally conscious.

Moreover, mental states can change over time, and some patients have almost completely recovered function after being thought vegetative. Brain imaging would be one way to track these changes, and even link them to efforts at treatment. Doctors have no cure for either a minimally conscious or persistently vegetative state.

"The most consequential thing about this is that we have opened a door, we have found an objective voice for these patients, which tells us they have some cognitive ability in a way they cannot tell us themselves," Dr. Hirsch said. The patients are, she added, "more human than we imagined in the past, and it is unconscionable not to aggressively pursue research efforts to evaluate them and develop therapeutic techniques."



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