Brain Death and the Persistent Vegetative State: Similarities and Contrasts

Young, Bradley W.; Blume, Warren T.; Lynch, Abbyann

doi:10.1017/s0317167100029437

Cited by 10 publications

(2 citation statements)

References 40 publications

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“…For example, one study conducted by Youngner and colleagues found that healthcare providers, including physicians involved in decision making as well as staff involved in care but less in decision making such as nurses and residents, conflate the persistent VS with brain death 43 . Such confusion has been found even among neurologists and neurosurgeons 44 and previously discussed in the Canadian context 45 . Previous research and common neurological perspectives on disorders of consciousness do not appear to have fully penetrated general healthcare knowledge and practice.…”

Section: Diagnostic Accuracy and The Need For Professional And Publicmentioning

confidence: 85%

Observations on the Ethical and Social Aspects of Disorders of Consciousness

Racine

Rodrigue

Bernat

et al. 2010

Can. j. neurol. sci.

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Disorders of consciousness such as coma, the vegetative state (VS), and the minimally conscious state (MCS) are neurological syndromes that disturb awareness or both wakefulness and awareness. Medical advances and neurotechnology have increased the probability of survival for patients suffering from severe neurological injury. Although coma rarely persists more than a few weeks, some patients remain in a VS or a MCS for years. The care of chronically unconscious patients raises vexing medical, ethical, and social questions concerning diagnosis, prognosis, communication with family members, and decision making, including the withdrawal of life support. Our goals here are to update the principal controversies surrounding disorders of consciousness and to discuss how scientific developments and social factors have lead to changes in the ethical landscape of these disorders. ABSTRACT:The care of chronically unconscious patients raises vexing medical, ethical, and social questions concerning diagnosis, prognosis, communication with family members, and decision making, including the withdrawal of life support. We provide updates on major controversies surrounding disorders of consciousness. Issues such as withdrawal of artificial nutrition and hydration -which had been considered "settled" by many in the medical, legal and ethical communities -have resurfaced under the pressure of social groups and religious authorities. Some assumptions about the level of awareness and the prognosis of vegetative state and minimal conscious patients are questioned by advances in clinical care because of insights produced by neuroscience research techniques, particularly functional neuroimaging. Both the clinical and neuroscience dimensions of disorders of consciousness raise complex issues such as resource allocation and high levels of diagnostic inaccuracies (at least, for the vegetative state). We conclude by highlighting areas needing further research and collaboration.RÉSUMÉ: Observations sur les aspects éthiques et sociaux des troubles de la conscience. La prise en charge de patients inconscients chronique soulève des questions médicales, éthiques et sociales qui sont éprouvantes en ce qui concerne le diagnostic, le pronostic, la communication avec les membres de la famille et les décisions à prendre, dont le retrait des mesures de maintien en vie. Nous faisons une mise à jour des grandes controverses concernant les troubles de la conscience. Les controverses telles le retrait de la nutrition artificielle et de l'hydratation -qui étaient considérées comme résolues par plusieurs membres des communautés médicale, légale et éthique -ont refait surface sous la pression de groupes sociaux et d'autorités religieuses. Certaines notions au sujet du niveau de conscience et du pronostic de l'état végétatif et les patients minimalement conscients, qui étaient tenues pour acquises, sont remises en question à cause des progrès dans les soins cliniques découlant des techniques de recherche en neurosciences, particulièrement de l'imagerie fonc...

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Section: Diagnostic Accuracy and The Need For Professional And Publicmentioning

confidence: 85%

Observations on the Ethical and Social Aspects of Disorders of Consciousness

Racine

Rodrigue

Bernat

et al. 2010

Can. j. neurol. sci.

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“…On the one hand, perhaps clinicians are blatantly wrong, or are what we could call in disagreement of knowledge with guidelines, i.e., they are or were wrong because they did not know. In support of this interpretation, research on diagnostic accuracy has shown that clinicians have trouble distinguishing the VS/UWS from MCS [59][60][61] and even confuse the VS/UWS with more remote states, like brain death and the locked in syndrome [62][63][64]. Knowledge disagreement could also be explained by the fact that, prior to the 2002 guidelines on MCS [4], MCS patients could have been clustered with VS/UWS patients within the broader category of vegetative patients.…”

Section: Evolving Scientific Understandings Of Pain Perception and Thmentioning

confidence: 99%

Pain Perception in Disorders of Consciousness: Neuroscience, Clinical Care, and Ethics in Dialogue

et al. 2012

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Pain, suffering and positive emotions in patients in vegetative state/unresponsive wakefulness syndrome (VS/UWS) and minimally conscious states (MCS) pose clinical and ethical challenges. Clinically, we evaluate behavioural responses after painful stimulation and also emotionally-contingent behaviours (e.g., smiling). Using stimuli with emotional valence, neuroimaging and electrophysiology technologies can detect subclinical remnants of preserved capacities for pain which might influence decisions about treatment limitation. To date, no data exist as to how healthcare providers think about end-of-life options (e.g., withdrawal of artificial nutrition and hydration) in the presence or absence of pain in non-communicative patients. Here, we aimed to better clarify this issue by re-analyzing previously published data on pain perception (Prog Brain Res 2009 177, 329-38) and end-of-life decisions (J Neurol 2010 258, 1058-65) in patients with disorders of consciousness. In a sample of 2259 European healthcare professionals we found that, for VS/UWS more respondents agreed with treatment withdrawal when they considered that VS/UWS patients did not feel pain (77%) as compared to those who thought VS/UWS did feel pain (59%). This interaction was influenced by religiosity and professional background. For MCS, end-of-life attitudes were not Neuroethics (2013) Author's personal copy influenced by opinions on pain perception. Within a contemporary ethical context we discuss (1) the evolving scientific understandings of pain perception and their relationship to existing clinical and ethical guidelines; (2) the discrepancies of attitudes within (and between) healthcare providers and their consequences for treatment approaches, and (3) the implicit but complex relationship between pain perception and attitudes toward life-sustaining treatments.6:37-50 DOI 10.1007/s12152-011-9149-

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