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Health See other Health Articles Title: In Scans, Patient Deemed ‘Vegetative’ Signals Yes or No He emerged from the car accident alive but alone, there and not there: a young man whose eyes opened yet whose brain seemed shut down. For five years he lay mute and immobile beneath a diagnosis — “vegetative state” — that all but ruled out the possibility of thought, much less recovery. But in recent months at a clinic in Liège, Belgium, the patient, now 29, showed traces of brain activity in response to commands from doctors. Now, according to a new report, he has begun to communicate: in response to simple questions, like “Do you have any brothers?,” he showed distinct traces of activity on a brain imaging machine that represented either “yes” or “no.” Experts said Wednesday that the finding could alter the way some severe head injuries were diagnosed — and could raise troubling ethical questions about whether to consult severely disabled patients on their care. The new report, posted online by The New England Journal of Medicine, does not suggest that most apparently unresponsive patients can communicate or are likely to recover. The hidden ability displayed by the young accident victim is rare, the study suggested. Nor does the finding apply to victims of severe oxygen depletion, like Terri Schiavo, the Florida woman who became unresponsive after her heart stopped and was taken off life support in 2005 during an explosive controversy over patients’ rights. Moreover, experts said the new test was not ready for wide use as a diagnostic tool; serious technical challenges remain to be worked out. Still, the experts agreed that the new study exposed the limits of the current bedside test for diagnosing mental state: checking whether patients’ eyes can track objects, and carefully looking for any signs — eye blinks, finger twitches — in response to questions or commands. “I’m convinced as an observer that in these few cases, the M.R.I. technique, in these researchers’ hands, gives us a window into human consciousness that we have not had and that potentially adds to the clinical exam we currently use,” said Dr. James L. Bernat, a neurologist at Dartmouth-Hitchcock Medical Center in New Hampshire. In the new paper, Belgian and English researchers studied 54 patients living in states of persistent unconsciousness. Of these, 23 had a diagnosis of “vegetative state,” meaning they were not able to signal any response to commands or questions. (The others were termed “minimally conscious,” meaning they were intermittently able to respond to commands by moving or blinking.) In 2006, the same research group reported that one of the 23 “vegetative” patients showed on imaging tests that her brain was responding to commands. When doctors asked her to think of playing tennis, areas of her motor cortex leapt to life. When asked to think of being in her house, spatial areas in the brain became active. In the current experiment, the researchers found that three other patients showed similar responses. To open a channel of communication, they instructed one of them, the 29-year-old man, to associate thoughts about tennis with “yes” and thoughts about being in his house with “no.” They then asked questions, repeating the procedure numerous times, switching the associations — tennis with yes, then with no — to make sure the patient was in fact making conscious choices. The researchers had previously tested the technique in healthy volunteers. “We asked basic biographical questions, like ‘Is your father’s name Thomas?’ and ‘Have you ever been to the United States?’ ” said Adrian M. Owen, a neuroscientist at the Medical Research Council in Cambridge, England, who developed the method and was a co-author of the paper. “We then checked whether the answers were correct. They were.” Dr. Owen’s co-authors were Martin M. Monti, Martin R. Coleman and John D. Pickard in Cambridge; and Audrey Vanhaudenhuyse, Dr. Mélanie Boly, Dr. Jean-Flory L. Tshibanda and Dr. Steven Laureys of the University of Liège in Belgium, where the patient was treated. Over all, only 5 of the 54 patients — four identified as vegetative and one as minimally conscious — showed any meaningful brain activity on the M.R.I. when prompted, perhaps because it was too feeble to be picked up, because the timing was wrong or because the activity simply was not there. In those rare cases where brain activity is detectable, doctors might be able to ask immobilized patient if they are feeling pain, for example, and, through a series of yes-or-no questions, where. A two-way channel to an immobilized, severely brain-injured person also opens up a world of ethical challenges. “If you ask a patient whether he or she wants to live or die, and the answer is die, would you be convinced that that answer was sufficient?” said Dr. Joseph J. Fins, chief of the medical ethics division at Weill Cornell Medical College in New York. “We don’t know that. We know they’re responding, but they may not understand the question. Their answer might be ‘Yes, but’ — and we haven’t given them the opportunity to say the ‘but.’ “We’ve opened up a communication channel with this technique, but in some ways it’s like a very bad cellphone connection.” In an editorial accompanying the article, Dr. Allan H. Ropper, a neurologist at Brigham and Women’s Hospital in Boston, similarly warned against equating neural activity and identity. “Physicians and society are not ready for ‘I have brain activation, therefore I am,’ ” Dr. Ropper wrote. “That would seriously put Descartes before the horse.”
Poster Comment: a. ...“I’m convinced as an observer that in these few cases, the M.R.I. technique, in these researchers’ hands, gives us a window into human consciousness that we have not had and that potentially adds to the clinical exam we currently use,” said Dr. James L. Bernat, a neurologist at Dartmouth-Hitchcock Medical Center in New Hampshire... b. ...A two-way channel to an immobilized, severely brain-injured person also opens up a world of ethical challenges. “If you ask a patient whether he or she wants to live or die, and the answer is die, would you be convinced that that answer was sufficient?” said Dr. Joseph J. Fins, chief of the medical ethics division at Weill Cornell Medical College in New York. “We don’t know that. We know they’re responding, but they may not understand the question. Their answer might be ‘Yes, but’ — and we haven’t given them the opportunity to say the ‘but.’...
Post Comment Private Reply Ignore Thread Top • Page Up • Full Thread • Page Down • Bottom/Latest Begin Trace Mode for Comment # 4.
#1. To: scrapper2 (#0)
It is very disconcerting to lie there, immobile, unable to communicate and yet hear and understand everything the medical staff is saying about you. My worst was in ICU, having a resident by my bedside, another one walk up and ask..."Is this guy still alive"...to which the first replies, "Yes but I dont know why or how". I wanted to scream at them, but of course could not.
Poor bedside manner. I thought med students were taught to treat the patient as if they can hear and understand all.
That was the best I could call it. Later, when I spoke with the doctor in charge of the residents, there was much hell to pay.
#5. To: Cynicom (#4)
Good, there should have been.
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