Monday, 23 May 2011

Should comatose patients’ lives be terminated?

Most people who find themselves having to make a decision of having the plug pulled on comatose relative — making end-of-life decisions for a loved one — generally know when it’s time. For those incapable or unwilling to let go, perhaps because they disagree with the assessment of expert physicians — there must be some procedure for appeal that respects all parties. It seems to me that the final decision should be made by a judge who is also a doctor who will review and weigh the evidence in as nonconfrontational a way as is possible under such distressing circumstances.

It shouldn’t be a unilateral decision by the attending physicians or even by a relative who is deemed to be the closest relative.

A comatose person is more than a patient. He or she is a human being for as long as a single breath can be taken, even when a machine is doing the breathing. No doctor should play the role of God, though far too many seem to think otherwise.

The ethical dilemmas are profound in a modern world where medical advances have blurred the definition of life, where debate rages over the difference between brain-dead and heart-dead — a distinction poorly understood by many who might some day have to confront the question of organ donation. It is not as simple, or obvious, as we have been led to believe.

Let me tell you of a specific case. It involves a 59-year-old comatose patient at Sunnybrook Health Sciences Centre in Toronto. The man’s wife (herself a doctor) and two children are insistent the man can hear and understand their voices, to the extent he would somehow make them understand if heroic measures at sustaining life were not desired.

His doctors claim the man is in a permanent vegetative — a grotesque term that implies that nothing more can be done, and their medical judgment compels them recommend the removal the ventilation system that is keeping the patient alive.

Ontario, unlike some other jurisdictions, has a venue for weighing such delicate conundrums. The Consent and Capacity Board is a provincial body that mediates end-of-life disputes so that doctors can’t proceed in the face of opposition until all parties are heard. But the two Sunnybrook doctors are seeking the right to go ahead and withdraw life support without first seeking permission from the board. A lower court decision has already ruled the doctors can’t unilaterally stop treatment.

The huge ethical quandary surrounding end-of-life decisions is now in the hands of a three-member Ontario Court of Appeal panel. Judges heard arguments Wednesday on whether the law requires doctors to obtain consent before withdrawing life-support from an unconscious patient or if they are entitled to make unilateral decisions to “pull the plug’’ — a grotesque expression — when families are vehemently opposed.

I’m deeply disturbed that any physician would presume to have the sole right to decided decide what’s in a patient’s best interest and attempt to deny the family even their own right to make the decision. An unconscious patient needs advocates, not a summary death sentence brought about by a doctor.

Patients have rights, even those barely clinging to their mortal coil. Families have rights also and that includes resisting the bullying of doctors who always profess to know what’s best, as if they were infallible. They’re not ethicists, they’re not priests and the existence of life, however feeble, can’t be measured solely by scientific apparatus and brain graphs although, for the most part, they are good indicators as to the status of the human brain.

Justice Michael Moldaver, a member of the appeal court that heard this case — its judgment pending —posed a question to the doctors’ lawyer: “Are we that impoverished a society that we’ll say, ‘We’ll just let him go?’ Why wouldn’t we look at it the other way and say, ‘Let this person keep going?’ ’’

In medicine, a coma is a state of unconsciousness, lasting more than 6 hours[1] in which a person cannot be awakened, fails to respond normally to painful stimuli, light or sound, lacks a normal sleep-wake cycle and does not initiate voluntary actions. A person in a state of coma is described as comatose.

Coma may result from a variety of conditions, including intoxication (such as illicit drug abuse, overdose or misuse of over the counter medications, prescribed medication, or controlled substances), metabolic abnormalities, central nervous system diseases, acute neurologic injuries such as strokes or hernias, hypoxia, hypothermia, hypoglycemia or traumatic injuries such as head trauma caused by falls or vehicle collisions. It may also be deliberately induced by pharmaceutical agents in order to preserve higher brain functions following brain trauma, or to save the patient from extreme pain during healing of injuries or diseases.

In order for a patient to maintain consciousness, two important neurological components must function impeccably. The first is the cerebral cortex which is the gray matter covering the outer layer of the brain, and the other is a structure located in the brainstem, called reticular activating system. Injury to either or both of these components is sufficient to cause a patient to experience a coma.

Physical examination is critical after stabilization. It should include vital signs, a general portion dedicated to making observations about the patient's respiration (breathing pattern), body movements (if any), and of the patient's body habitus (physique); it should also include assessment of the brainstem and cortical function through special reflex tests such as the oculocephalic reflex test (doll's eyes test), oculovestibular reflex test (cold caloric test), nasal tickle, corneal reflex, and the gag reflex.

Vital signs in medicine are temperature (rectal is most accurate), blood pressure, heart rate (pulse), respiratory rate, and oxygen saturation. It should be easy to evaluate these vitals quickly in order to gain insight into a patient's metabolism, fluid status, heart function, vascular integrity, and tissue oxygenation.

Respiratory pattern (breathing rhythm) is significant and should be noted in a comatose patient. Certain stereotypical patterns of breathing have been identified including Cheyne-Stokes a form of breathing in which the patient's breathing pattern is described as alternating episodes of hyperventilation and apnea. This is a dangerous pattern and is often seen in pending hernias, extensive cortical lesions, or brainstem damage.[2] Another pattern of breathing is apneustic breathing which is characterized by sudden pauses of inspiration and is due to a lesion of the pons.
Ataxic breathing is irregular and is due to a lesion (damage) of the medulla.

Assessment of posture and body habitus is the next step. It involves general observation about the patient's positioning. There are often two stereotypical postures seen in comatose patients. Decorticate posturing is a stereotypical posturing in which the patient has arms flexed at the elbow, and arms adducted toward the body, with both legs extended. decerebrate posturing is a stereotypical posturing in which the legs are similarly extended (stretched), but the arms are also stretched (extended at the elbow). The posturing is critical since it indicates where the damage is in the central nervous system. A decorticate posturing indicates a lesion (a point of damage) at or above the red nucleus, whereas a decerebrate posturing indicates a lesion at or below the red nucleus. In other words, a decorticate lesion is closer to the cortex, as opposed to a decerebrate cortex that is closer to the brainstem.

Oculocephalic reflex also known as the doll's eye is performed to assess the integrity of the brainstem. Patient's eye lids are gently elevated and the cornea is visualized. The patient's head is then moved to the patient's left, to observe if the eyes stay or deviate toward the patient's right; same maneuver is attempted on the opposite side. If the patient's eyes move in a direction opposite to the direction of the rotation of the head, then the patient is said to have an intact brainstem. However, failure of both eyes to move to one side, can indicate damage or destruction of the affected side. In special cases, where only one eye deviates and the other does not, this often indicates a lesion (or damage) of the medial longitudinal fasciculus which is a brainstem nerve tract. Caloric reflex test also evaluates both cortical and brainstem function; cold water is injected into one ear and the patient is observed for eye movement; if the patient's eyes slowly deviate toward the ear where the water was injected, then the brainstem is intact, however failure to deviate toward the injected ear indicates damage of the brainstem on that side. Cortex is responsible for a rapid nystagmus away from this deviated position and is often seen in patients who are conscious or merely lethargic.

An important part of the physical exam is also assessment of the cranial nerves. Due to the unconscious status of the patient, only a limited number of the nerves can be assessed. Gag reflex helps assess cranial nerves. Pupil reaction to light is important because it shows an intact retina, and if pupils are reactive to light, then that also indicates that its parasympathetic fibers are intact. Pupil assessment is often a critical portion of a comatose examination, as it can give information as to the cause of the coma; the following table is a technical, medical guideline for common pupil findings and their possible interpretations.

Generally, a patient who is unable to voluntarily open the eyes, does not have a sleep-wake cycle, is unresponsive in spite of strong tactile (painful), or verbal stimuli and who generally scores between 3 to 8 on the Glasgow Coma Scale is considered to be in coma

There are some things that we as society must consider when making a descison to pull the plug on a comatose person.

First, there are many instances when comatose persons who were considered brain dead, finally came out of the comatose state and lived a normal life. Some level of consciousness is present as long as there is breath. And that we can communicate with people in any state of consciousness, including sleep or a supposed state of unconsciousness. People with traumatic brain injury usually remain in a so called true coma for about two weeks to a month, where they have no sleep/wake cycle. They then change to a vigil coma, commonly called vegetative state, where they exhibit sleep/wake cycles, including opening and closing their eyes. The vigil coma is also known as minimal consciousness or severely altered consciousness. Patients in true coma may be more or less aware at any one time of what is happening around their beds. People in vegetative states or altered consciousness are more aware and less aware at times, like all of us. Sometimes comatose patients are totally unaware of their states and environments; sometimes they are partially or fully aware but cannot communicate.

Always assume the person in coma can hear. Hearing is usually the last sensory faculty to deteriorate when people are dying. Occasionally someone hard of hearing in their normal state can hear better in their altered consciousness. It would be horrific to discuss pulling the plug in a comatose case within earshot of the victim.

When the coma person’s eyes are open they may well be able to see. Many patients track movements, focus on objects, and make eye contact. They may not do these things all the time.

The diagnosis of coma has become one of the biggest battlegrounds in medical care. While some doctors insist that comatose patients will never recover and should be starved, dehydrated to death or be denied oxygen and suffer from suffocation, there are examples of people who have emerged from comas to live full and productive lives which can be found around the world. One person finally became fully conscious after being thirty years in a coma.

Dr. Mihai Dimancescu, chairman of the board of the Coma Recovery Association, writes on the group's web site that coma should be defined as "a state of unresponsiveness from which an individual has not yet been aroused." Many patients emerge from comas, even after months in the condition.

Dr. Dimancescu explains that the characteristics of coma vary from patient to patient, with some people able to hear what is going on around them even if they cannot interact with anyone. "While a person described as being in a coma may be totally unaware of his or her state or environment," he writes, "others may have some or even full awareness, contrary to our own perception of their condition." Medical science has not yet advanced enough to be able to determine exactly why most comas occur or which patients will survive and which will not.

He tells of 23-year-old Judy, who was in a coma for three months. A professor, making daily rounds with his medical students, would pass by Judy's bed every day, saying, "Judy is in a coma. She'll never wake up." According to Dr. Dimancescu, Judy came out of her coma and told him she "always remembered that darn professor refusing to stop by her bed, saying that she would not wake up!"

Patients like Judy, dismissed by medical caregivers as all but dead, can and do wake up. The St. Louis Post-Dispatch published an extensive profile of Brian Cressler, who spent 18 months in a coma caused by a car accident a few weeks after his high school graduation in June 1991.

Cressler's parents, Don and Fran, took him home from St. Louis University Hospital in January 1992. Brian couldn't move or talk, his eyes locked in a blank stare. "It was a look that went right through you," said Fran Cressler, according to the Post-Dispatch.

The Cresslers cared for him, hired a physical therapist to keep his muscles from atrophying, and didn't stop hoping. A year and a half after the accident, they noticed a change.

"You could see a slow awakening," Fran Cressler told the Post-Dispatch. "It was like he was talking through his eyes. They just came alive."

He started speaking six months later—his first word was "Mom." "It was pure joy," Mrs. Cressler said.

Although Brian's body will never be the same since his accident -- he only has partial use of one limb and has memory problems and seizures -- he is able to do many things with the help of his parents, his wheelchair, and a specially trained dog named Sara.

The doctors who treated him right after his accident are astonished by his progress. "When I think about Brian, I think about when I first saw him in the intensive care unit and so close to death," neurosurgeon Robert J. Bernardi told the Post-Dispatch. "Now, when his parents come in with pictures of him hitting tennis balls in his wheelchair and swimming laps in a pool, it's hard to imagine."

Brian Cressler's story is remarkable, but not unique. Patients who emerge from coma have often received therapy consistently, to stimulate their brains and keep their bodies moving.

There is a growing "recognition that people who have some kind of a brain injury, even if they're in a coma for several weeks, do have the potential for recovery," Dr. Dimancescu told the National Catholic Register. "New connections can be made between brain cells where connections have been lost. Parts of the brain take over the function of other parts that have been lost."

The challenge is to convince doctors and hospitals to give the patients time to wake from a coma. but the real challenge facing not only the doctors but also the families is, “How long should they wait?” I don’t think anyone can honestly come up with an answer that will satisfy everyone.

Even patients who spend years in a coma-like state have come fully back to consciousness. Patricia White Bull of Albuquerque, New Mexico, was unresponsive for 16 years after suffering a lack of oxygen while giving birth to her son, Mark, the Associated Press (AP) reported. This case and others like it is evidence that doctors' predictions are often wrong.

One factor that has to be seriously considered is the cost of keeping a comatose person alive.

Such a victim in the State of Florida was Terri Schiavo who entered a vegetative state in 1990 after adopting an "iced tea diet" (related to her bulimia), resulting in a disastrous potassium deficiency that caused irreversible brain damage. In this persistent vegetative state she remained the last fifteen years of her life. Both Schiavo's doctors and her court-appointed doctors expressed the opinion that there existed no hope of rehabilitation. Her husband, Michael Schiavo on the other hand contended that it was his wife's wish that she not be kept alive through unnatural, mechanical means. Michael Schiavo wanted her feeding tube removed, after which Terri would slowly die of malnutrition and dehydration. By this time Michael had taken a new lover, but refused to divorce Terri, as doing so would have forfeited his right to determine her care.

I don't think anyone would want to die slowly by being starved to death and dying of thirst because their feeding tube has been removed. If the comatosed person's life is to be terminated, then let it be done quickly, such as the injection of a fatal drug that will terminate the life of the comatose victim almost immediately.

More than twenty times the Schiavo case was heard in Florida courts. Every time, the court ruled that the decision was her husband's to make, upholding the sanctity of marriage long respected by legal precedent. Schiavo's parents, Bob and Mary Schindler, refused to accept this verdict, feeling in their hearts that their daughter would somehow recover. Of this struggle, Schiavo's attorney, George Felos told the Associated Press, "The real grievance is not they (the Schindlers) did not have a day in court, that they did not have due process. The real grievance is they disagree with the result."

The Schindler family videotaped Schiavo for extended periods of time, discarding nearly all of the footage, and prepared a short but disingenuous "highlight" video featuring only the occasional moments when her facial expression looked vaguely like a smile, or when family members were posing where Schiavo seemed to be staring, giving the illusion of "eye contact."

In 2003, a court-appointed guardian for Schiavo wrote that during the protracted legal struggle, her parents had "voiced the disturbing belief that they would keep Terri alive at any and all costs", even if that required amputation of her limbs. "As part of the hypothetical presented", the guardian's report stated, "Schindler family members stated that even if Terri had told them of her intention to have artificial nutrition withdrawn, they would not do it."

Politicians inserted themselves into the fray. The case was the catalyst for Florida's controversial "Terri's Law", which gave Gov. Jeb Bush the authority to have Schiavo's feeding tube re-inserted when a court ruled that her husband could have it removed.

Terri's doctors opinion was that Schiavo's coma had been caused by a potassium imbalance triggered by her bulimia. Nutball "save Terri" activists knew better, and claimed she suffered a violent beating at her husband's hand. Her parents eventually agreed, and said that her husband often beat Schiavo when she was healthy—but Schiavo never called the police, apparently never mentioned it to anyone, and her parents never mentioned it either until years after Schiavo was hospitalized. There is no evidence to support such claims.

The U.S. Congress quickly passed legislation allowing federal courts to intervene, and President George W. Bush flew back to Washington to sign the bill into law. It should be noticed that this is the same George W. Bush who, as Governor of Texas, signed into state law the power of hospitals to remove a patient (in identical situations as Terri's) from life support—a critical factor being the family's ability to pay the hospital bills —even if such removal was against the family's objections.

As the insanity moved to the federal level, Schiavo's feeding tube was finally removed on March 18, 2005, and her heart stopped beating 13 days later.

In a final postscript to Schiavo's short life, the autopsy conducted after her death established that her brain damage was even worse than experts had said while she was alive, and that virtually everything the "save Terri" activists had said was incorrect. Schiavo's brain weighed about half what a healthy human brain weighs, damage that left her unable to think, feel, see, or interact in any way with her environment. There was no chance she could have recovered, and no evidence she had ever been abused.

This means that all the time she was comatose in the hospital, the taxpayers of Florida were paying the costs of keeping her alive. As it turned out, the money spent was for nothing. Imagine if you will, what the cost would have been if she was kept alive for another 15 years.

Normally a hospital stay can cost as much as $600 a day. Now multiply that by 365 days and that comes out to $219,000 a year. Now multiply that by 15 years and that would have cost the Florida taxpayers at least $3,285,000. And if she remained in the hospital for another 15 years, they would have paid $6,570,000. At what point would the taxpayers finally scream, “ENOUGH IS ENOUGH.” Imagine if you will, the taxpayers in a small town being stuck with those kinds of costs.

I have sincere sympathy for the families of such comatose victims and also for the doctors and nurses caring for them. I certainly wouldn’t want to be making a decision for them.

But someone has to make it. As I see it, only judges in the high courts such as appeal courts should be making those kinds of decisions.

As soon as I learn what the decision of that court is with respect to the 59-year-old comatose patient at Sunnybrook Health Sciences, I will write it as an UPDATE at the end of this article which my readers can then go back to it to find out the court’s decision.

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