NeuroRehabilitation

Jewish law allows removal of life-support systems that are impeding the natural process of dying in a terminally ill patient, but it forbids hastening that process. The tradition measures death primarily in terms of cessation of respiration and, for some, cessation of heartbeat as well. Nevertheless, most, but not all, rabbis writing on bioethics permit the use of full brain death (including the brain stem) to determine death, either because the apnea test now used in consort with other neurological criteria to determine brain death fulfills the tradition's demand for cessation of respiration, or because brain death amounts to decapitation, another traditional sign of death. Since PVS patients fulfill none of these criteria, most rabbis consider them alive, but some would permit withholding or withdrawing artificial nutrition and hydration.

Over the past 30 years, there has been an ongoing evolution in the nomenclature used to describe individuals in low-level neurological states. The appropriateness of historically well-entrenched nomenclature germane to persons in low level neurological states following brain injury continues to be debated. The effort to develop a cross disciplinary uniform set of descriptive terms for individuals in such states has continued to evolve as efforts for interdisciplinary collaborative consensus and guideline development has continued to make progress over the last decade. The intent of this article is to provide clinicians with a better understanding of some of the history behind the nomenclature, as well as, some ongoing controversies, caveats and conundrums that face us as health care professionals as related to the development of a rationale, uniform nomenclature for this special population of neurological patients.

Disorders of consciousness continue to be the subject of hot debate in healthcare settings, research consortiums, bioethics departments and media forums. There are no standards of care to guide assessment and treatment decisions resulting in wide disparities in daily practice. In response to this problem, expert panels in neurology and neurorehabilitation were convened and charged with developing consensus-based definitions and diagnostic criteria for disorders of consciousness. The Multi-Society Task Force Report on the persistent vegetative state and the Aspen Workgroup statement on the minimally conscious state represent two such initiatives. This paper summarizes the practice recommendations proposed by these groups and discusses their implications for existing and future interventions.

Withdrawal of nutrition and hydration, is a difficult and sensitive issue for all those working with people in the vegetative state. There are arguments against the decision to withdraw any treatment that might result in the patient deteriorating or dying. These arguments include the view that all life is worth having, that we can never be certain that the patient is not aware, and concerns that there may be new scientific developments in the future from which the patient would benefit. Others argue that the patient has no interests in life; that it is undignified, if not an assault, to insert tubes into a permanently unconscious person; that very few people would want to survive in this condition; and that it prevents loves ones from grieving. These strongly held opposing views can make clinical decision making very difficult for the clinician.

Once the decision has been made to withdraw treatment then the clinician has to be certain that the patient is in the vegetative state, that there are no factors preventing the patient demonstrating awareness, that he has received expert assessment and treatment, and that the prognosis for lack of recovery is as clear as it can be. It is important to support family and staff throughout this process.

The concept of withdrawal of nutrition and hydration is a sensitive issue and clinicians can expect to be considered as not acting in the patient's best interest whatever decision is taken.

The article focuses on the philosophical, ethical and juridical problems concerning Advance directives and Living Wills (underlining analogies and differences). The author makes a critical comparison between the theories supporting Living Wills (the liberal theory appealing to the principle of self-determination and the utilitarian theory on the “quality of life”) and the reasons against them (with reference to the foundation of the absolute value and dignity of human life till the end).

The withdrawal of assisted nutrition and hydration (ANH) is increasingly supported by scientific societies, by hospitals and by some families, once the condition of vegetative state could be considered permanent. In the first part of this article, the authors present the factors used to support the decision to withdraw ANH: a) the prognostic evaluation about outcome transformed into a clinical diagnosis of permanency; b) basic health care transformed into a medical treatment, subject to refusal by the patient; c) the human life (an undisposable good) transformed into a disposable one, open to decisions made by surrogates; d) the evaluations about quality of life transformed into judgments about the indignity of human life to be lived. In the second part, the authors outline the changes that this attitude can provoke in the integrity and the juridical status of the medical and nursing professions, and its potential impact on the society at large.

Event-related potentials (ERPs) can provide valuable information about cognitive capabilities in severely brain-damaged patients. This study examined 120 patients with severe brain damage using event related potentials ERPs (N 400) to gain information about their remaining semantic processing capabilities and to contribute to differential diagnosis. Patients were classified into three diagnostic groups: patients in vegetative state (VS), patients in near vegetative state (NEVS) and patients not in vegetative state (NOVS). N400 ERPs were analyzed on an individual basis. All three groups could be differentiated by N400. While VS-patients as a group were least likely to show N400, some VS-patients (approx. 12%) showed clear semantic N400 potentials as an indication of semantic processing capabilities. Patients in NEVS showed significantly more intact semantic capabilities (76.74%) than the VS-group despite little clinical differences between the two groups. Thus, ERPs provide valuable information about patients with brain injury whose clinical conditions often do not allow a true assessment of their cognitive capabilities. Given these findings, we would espouse that both ethical and legal debate should take into account results of ERP studies of such patients.

The interest of functional imaging in patients in a vegetative state is twofold. First, the vegetative state continues to represent a major clinical and ethical problem, in terms of diagnosis, prognosis, treatment, everyday management and end-of-life decisions. Second, it offers a lesional approach to the study of human consciousness and adds to the international research effort on identifying the neural correlate of consciousness. Cerebral metabolism has been shown to be massively reduced in the vegetative state. However, recovery of consciousness from vegetative state seems not always associated with substantial changes in global metabolism. Recent PET data indicate that some vegetative patients are unconscious not just because of a global loss of neuronal function, but due to an altered activity in a critical fronto-parietal cortical network and to abolished functional connections within this network and with non-specific thalamic nuclei. Recovery of consciousness was shown to be paralleled by a restoration of this cortico-thalamo-cortical interaction. Despite the metabolic impairment, external stimulation still induces neuronal activation as shown by both auditory and noxious stimuli. However, this activation is limited to primary cortices and dissociated from higher-order associative cortices, thought to be necessary for conscious perception.

Neurophysiological research on the vegetative state (VS) presupposes a clearly defined patient population. VS has been variously defined in three domains: anatomy, behavior, and consciousness. Research on each conceptual type of “VS” is reviewed. Certain key elements of official VS dogma are cast into doubt or flatly contradicted by recent noninvasive neurophysiological studies. “Behavioral VS” is often the manifestation of a multi-modular disconnection syndrome rather than the complete absence of cortical functioning. Some “behavioral VS” may represent a “super locked-in state,” with some primitive awareness of self and environment, including the capacity to experience pain. The term VS should be dropped and replaced with one that reflects what is truly known and verifiable about the condition and the individual patient.

This article intends to precise the anthropologic fundaments of the Persistent Vegetative State starting from the concept of the human person, as it has been described in relation to the philosophical-theological thought of Thomas Aquinas and other more recent personalists (J. Maritain, E. Mounier, E. Gilson, S. Vanni Rovighi). This view is largely shared by the catholic thought and is present in the Teachings of the Catholic Church. The central point of reflection is in affirming the double unity of the human person: the substantial unity of the spiritual body-soul; the uniqueness of the animative principle (soul) as “form” of corporeity. The spiritual soul is the active principle not only of the superior activities (thought, liberty) but also of the vegetative-sensitive activity of the organism which is part of the person. Thus, as long as a vital unit exists in the individual person, there will exist the presence of a spiritual soul in the organism, defined as a whole unit, and the subject must be considered alive, even when gravely and persistently hindered in the application of his/her cognitive functions.

In a context of limited resources and continuous increase of healthcare expenditures, policy makers need to carefully evaluate the economic impact of their decisions. In the last decade economists have been particularly productive in offering to the decision makers a set of tools able to compare costs and benefits of each single medical procedure. The underlying assumption is that it is not acceptable the investment of considerable amounts of resources in medical procedures able to guarantee only limited improvements in health outcomes.

In this particular type of context, an open issue is represented by the delicate topic of the provision of prolonged life sustaining treatments (PLST) to patients in vegetative state. The author, sustains that the provision of this type of treatments can be justified under a mere economic perspective. The traditional economic evaluations focus their attention only to the concept of incremental absorption of resources failing to capture other relevant dimensions: total costs and budget impact. The overall cost related to PLST due to the relative low unit cost and the low prevalence of patients in need of these treatments, represents a negligible part of the total health care budget. Hence, the emphasis on costs, in this circumstance, is misleading, especially considering that the current health care systems in the developed countries are characterized by wastes and inefficiencies that unduly increase costs. In addition, PLST provide a high return in terms of new knowledge, giving valuable insight on the clinical management of other severe health conditions. Long term therapies can also be considered a highly effective learning environment for health professionals. Finally, prolonged life therapies and treatments can also be considered an environment for experimenting “creative” solutions and approaches.

A wide range of medical, legal and ethical opinion regarding withholding or withdrawing medically assisted nutrition and hydration (ANH) from vegetative state (VS) and persistent vegetative state patients (PVS) has been presented in professional journals over the past twenty years. This article concerns the moral aspects of this debate as it has developed within the Catholic Church, especially in the United States. It presents traditional Catholic teaching about the extent and limits of the moral obligation to employ medical means in the preservation of human life, and examines how this teaching applies to the specific question of supplying ANH to PVS patients. It provides a critique of two contradictory views on the morality of discontinuing ANH for PVS patients presented by Catholic theologians. It examines the teaching of Pope John Paul II, who identifies ANH as a natural means of preserving life that must be maintained as long as it preserves the patient's life or alleviates his suffering. Finally, it discusses the practical implications this papal teaching has for the treatment of PVS patients in all Catholic health care facilities.

Jennett and Plum's 1972 naming of post-coma unresponsiveness as “persistent vegetative state (PVS)” characterised the condition as essentially irrecoverable and insentient. The evidence for these propositions was always weak, and they have been largely disproved by more recent research. Nonetheless, the definition and the attitudes it embodies remain generally accepted, resting as they do on a firm foundation of medical attitudes to disability and a public eagerness to evade uncomfortable facts. The first step in altering our approach to people with this form of communication impairment must be to rectify our understanding of the terminology.

The topic of therapeutic proportionality represents one of the main emerging issues in the contemporary bioethical debate. This paper intends to outline the development of moral doctrine on the use of therapeutic means. It first presents a synthesis of the reflection produced by moral Tradition with the definition of the concept of “ordinary and extraordinary means”; then the official teaching of the Catholic Church on the subject is summed up briefly up to the present day and finally, on the basis of the main points which will emerge during this itinerary, the author proposes his own attempt to create a new synthesis on the ethics of the use of therapeutic means. Such synthesis, which the author terms as “the principle of ethical suitability in the use of means for the preservation of life”, is an evaluative dynamism which, continuing along the lines set out by classical terminology (ordinary and extraordinary means), tries to apply the contents of moral Tradition to the new emerging perspective (proportionate and disproportionate means), underlining the specificity of each term, in a context of ethical systematization able to provide concrete evaluation criteria, at the service of the practical choices of patients and health care personnel.