9781402026294

Conscious In A Vegetative State?

by
  • ISBN13:

    9781402026294

  • ISBN10:

    1402026293

  • Format: Hardcover
  • Copyright: 2004-12-30
  • Publisher: Kluwer Academic Pub
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Summary

Having been originally introduced as a term to facilitate discussion of a specific group of patients regarded as entering a state of unawareness following coma, the a??Persistent Vegetative Statea?? (PVS) has established itself as an apparently discrete medical condition with clear-cut implications for ethicists and lawyers that exceed any scientifically based understanding. As a consequence of this upgrading, conclusions drawn about the status and hence the management of this uncommon condition have been increasingly extended to other patients with much more common forms of disability. This book traces the origins of prevailing perceptions about PVS and submits these to critical examination. In doing this it comes to the conclusion that inadequate attention has been paid to acknowledging what is not known about affected individuals and that assumptions have consistently come to be traded as facts. Re-examination of the basis of the PVS and the adoption of a more scientific approach is long overdue and is owed to the community at large which has generally been provided by many medical practitioners with a a??dumbed-downa?? account of the condition. The book will be of interest to philosophers, medical graduates and neuroscientists but is also intended to remain accessible to the general reader with an interest in the wider implications of trends in medical thinking for attitudes towards many classes of patient. It has an extensive bibliography and will be of specific interest to bioethicists and lawyers with professional interests in PVS.

Table of Contents

Acknowledgements xiii
Introduction xv
History and Context of the Persistent Vegetative State
1(28)
Twenty-five years on: an idea
1(2)
Responses to an idea
3(2)
The naming of PVS
5(3)
Pre-existing names
8(2)
Perceptions engendered by a name
10(3)
The interface between PVS and brain death
13(3)
Revising brain death: implications for PVS
16(2)
Semantic implications
18(1)
Evolution of the title
19(1)
Alive or dead?
20(1)
Dying for how long? An exercise in terminal semantics
20(1)
Artificial hydration, nutrition and semantics
21(2)
PVS and the right to die movement
23(4)
Utilisation of PVS patients
27(1)
Personhood and PVS
28(1)
The Pathological Basis of Vegetative States
29(14)
Interpretation of the pathological features of patients in vegetative states
31(1)
Early pathological reports of patients in a vegetative state
32(2)
Neuropathological features of two defining cases of persistent vegetative state
34(2)
Neuropathological reports of series of patients in vegetative states
36(2)
Neuropathological delineation of the PVS from the locked-in syndrome
38(1)
Effects of medical management on PVS pathology
39(1)
Deafferentation as a factor impeding assessment of conscious status
40(1)
From the individual to the general: perceptions of typical PVS neuropathology and personhood
41(1)
Recapitulation
41(2)
Authoritative Statements
43(15)
Authoritative statements and guidelines
43(1)
The American Academy of Neurology (A.A.N.) guidelines
44(2)
The American Medical Association (A.M.A.) report
46(1)
The American Neurological Association (A.N.A.) statement
47(1)
The Multi-Society Task Force (M.S.T.F.) on PVS consensus statement
48(5)
Other U.S. reports
53(2)
U.K. statements
55(1)
Recapitulation
56(2)
Consciousness
58(27)
Relevance of studies of consciousness to its definitional absence in PVS
59(2)
Terminology
61(3)
Vigilance: attention: habituation
64(4)
Neuroanatomical and neurophysiological aspects of consciousness
68(4)
Communication
72(1)
Unconscious mental activity
73(5)
Personhood and PVS
78(5)
Recapitulation
83(2)
Sentience
85(15)
Statements on sentience from authoritative sources
88(2)
Assessing sentient status - individual patients' experience
90(2)
Assessing sentient status - neuroanatomical requirements
92(3)
Assessing sentient status - clinical tests
95(1)
Responses of others to the possibility of retained or regained sentience on the part of a patient in a PVS
96(1)
The use of analgesic agents in managing PVS patients
97(1)
Recapitulation
98(2)
Electrophysiological and Imaging Studies of Patients in Vegetative States
100(31)
The electroencephalogram (EEG)
101(4)
Somatosensory evoked potentials (SEP)
105(3)
Imaging of the brain
108(1)
Structural imaging: computed tomography (CT) scanning
109(1)
CT indications of brain atrophy in neurologically intact subjects with anorexia nervosa
110(4)
Functional imaging: cerebral blood flow
114(2)
Functional imaging: magnetic resonance
116(1)
Functional imaging: positron emission tomography (PET): the first study of patients in a PVS
116(2)
The equivalence of PVS and anaesthesia?
118(2)
The inconsistency between level of anaesthesia and depression of cerebral metabolism
120(2)
Subsequent PET studies of patients in a PVS
122(2)
Inter-subject variation in PET-calculated cerebral metabolic rates
124(1)
PET assessment of changes in cerebral metabolic rate during development
125(1)
Sedatives and PET-calculated cerebral metabolic rates
126(1)
Influence of brain atrophy on brain metabolism studies
127(1)
Location of lesions in vegetative patients using PET
128(1)
Recapitulation
128(3)
An Analogy between Anaesthesia and the Persistent Vegetative State
131(10)
The issue of awareness under anaesthesia at the time of the M.S.T.F. statement
132(1)
Inferences about unconscious subjects from study of anaesthesia
132(1)
Research protocols in the study of awareness under anaesthesia
133(1)
Type and depth of anaesthesia
134(1)
Positive suggestion under anaesthesia
135(1)
Emotional content of stimulus
136(1)
Amnesia following anaesthesia and unconsciousness
137(3)
Recapitulation
140(1)
Diagnosis and Misdiagnosis of Vegetative States
141(19)
The place of guidelines
142(3)
Probability and prediction
145(4)
Frequency of misdiagnosis of PVS
149(4)
Diagnosis in court
153(1)
The ultimate misdiagnosis - locked-in syndrome
154(4)
Implications of a misdiagnosis of locked-in syndrome for patient management
158(1)
Recapitulation
159(1)
Emergence from a Vegetative State
160(15)
Frequency of emergence from PVS
163(2)
Individual cases of emergence: medical literature
165(1)
Emergence in the non-medical press: a cluster of cases
166(4)
Recognition of emergence
170(3)
Recapitulation
173(2)
A Perspective of Disability
175(18)
Assessments by the non-disabled of the wishes of those with a disability
177(1)
Perceptions of non-disabled medical attendants about people with severe neurological damage
178(2)
Family views about severely disabled members
180(1)
Patient views
181(2)
The remarkable Jean-Dominique Bauby
183(1)
Treatment preferences of severely disabled people
184(3)
Quality of life issues
187(1)
The question of indignity
188(1)
Social isolation
189(1)
Depression
190(1)
Dependency
191(1)
Recapitulation
192(1)
Positive Management or an Exercise in Futility?
193(24)
Attitudes towards management of PVS
194(1)
A rehabilitation approach
194(2)
Avoiding complications
196(1)
Nutrition
197(1)
Oral versus tube feeding
198(1)
Nutrition and neuronal multiplication
199(1)
Sedation and recovery from brain injury
200(1)
Carers - the family role
200(2)
Care of the carers
202(1)
Active intervention to interrupt the vegetative state
202(3)
The influence of prognostic negativity
205(1)
Establishing communication
206(2)
The issue of futility
208(2)
Who determines futility?
210(2)
Futility and resource allocation
212(1)
Is maintenance without recovery a futile goal?
213(2)
Recapitulation
215(2)
Thirst
217(16)
Thirst in the context of PVS
218(1)
Sources of information about capacity for thirst
219(1)
Basic neuroanatomy and neurophysiology
220(1)
Dehydration in healthy volunteers
221(1)
Adipsia and hypodipsia
222(2)
Dehydration in terminally ill patients
224(2)
Experimental studies of thirst in animals
226(3)
Relief of thirst sensation without correction of dehydration
229(2)
Recapitulation
231(2)
Withdrawal of Hydration and Nutrition from Patients in Vegetative States
233(28)
From ventilator disconnection to withdrawal of hydration and nutrition
234(3)
Withdrawing options
237(2)
Acts versus omissions
239(2)
Withholding versus withdrawing
241(1)
Care versus cure
242(1)
Tube feeding - nursing care versus medical treatment
243(4)
Is retention of the capacity for oral feeding significant?
247(2)
The cause of death after withdrawal of hydration and nutrition
249(2)
Clinical course following withdrawal of hydration and nutrition
251(1)
Analgesia and sedation during withdrawal of hydration and nutrition
252(2)
Making the decision to withdraw hydration and nutrition
254(2)
Differing roles for families in decision-making
256(3)
A postscript on decision-making outcomes
259(1)
Recapitulation
259(2)
Some Economic Considerations
261(21)
Allocation of health-care resources within a social contract
261(6)
Allocation and reallocation of resources to patients following a PVS diagnosis
267(3)
Economic implications of varying intensity of care of PVS patients
270(4)
Family implications
274(2)
Global costs of PVS to health care systems
276(1)
Costs of caring for PVS patients in a specialised facility
277(2)
Prevalence of PVS
279(1)
Recapitulation
280(2)
Vegetative States in Court
282(33)
PVS court cases as a representative sample of PVS
282(3)
The use of advance directives in PVS cases
285(5)
Surrogate decision-making
290(1)
Interests as the basis for decisions
291(2)
Legal consideration of life-support systems
293(1)
PVS in continental European courts
294(1)
The UK test case: Airedale NHS Trust v Bland
295(1)
Medical advances as a source of new ethical problems
296(3)
Tube v mouth: medical v non-medical procedures
299(1)
Whatever happened to intent?
300(1)
The Bland case as a precedent
301(1)
Publication and patient confidentiality
302(1)
Incidence of PVS court cases after Airedale NHS Trust v Bland
303(1)
Entrenchment of PVS as a single entity
303(2)
Whose interests?
305(3)
Time for consideration
308(2)
Legal euphemisms
310(2)
What was the question addressed by the courts in Airedale NHS Trust v Bland?
312(1)
Recapitulation
313(2)
Continuing Unresponsiveness in the Future
315(10)
A more objective nomenclature is required
315(1)
Possibilities for prevention of PVS should be explored
316(2)
Policy formulation should be responsive to adequately informed community input
318(1)
Neuro-rehabilitation should be instituted earlier after brain injury
319(1)
Diverse medical and paramedical skills are required in the management of patients who remain unresponsive after brain injury
320(1)
Resources should be provided for specialised facilities which are likely to have a higher rehabilitation success rate
321(1)
Patients do better when fed
322(1)
Research with patients in vegetative states is needed to improve management
323(1)
In conclusion
324(1)
References 325(22)
Index 347

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