Communication In A Persistent Vegetative State?

A recent New York Times article found that by using functional MRIs on long term persistent vegetative state patients, a few could hear and process information.  The idea sounds exciting, helping differentiate those who had residual brain function from the majority that did not.  But a few caveats are in order:

1.  Even those who have brain function may never be able to emerge from a comatose state, with even fewer able to regain the ability to live a good life.

2.  Functional MRI studies, while exciting, are plagued with inaccuracies.  For instance Science Daily tells of FMRIs on dead fish that register activity.  The procedure may be better in the future, but still needs improvement.

3.  Interpretation of FMRI results is difficult.   We know it is not true that only one part of the brain correlates to one function.  Brain processes are complex and often non-localized.

4.  The cost of an FMRI is prohibitive.  New 1.5 tesla scanners may cost  $1,500,000 and new 3.0 tesla scanners $2,300,000, plus a half million dollars for the suite to use it and a few hundred thousand annually for liquid nitrogen and helium.  These are not common in hospitals and our country does not fund low cost primary care visits ostensibly because of cost.

5.  The growth of nerves, neurogenesis, is relegated to very limited, specific brain regions and the individual will not likely regain cortical mass or function.

6.  Persistent vegetative states are different from comas or being brain dead.  There is no evidence that the brain dead can revive.  PVS patients are conscious unlike the comatose (who do have intermittent moments when they seem to understand.)

7.  Scientists are not in accord that the highlighted areas showing activity are meaningful in the same way that undamaged brains are.  In the study cited little could be determined by asking for “Yes” or “No” answers so they asked people to think of playing tennis for yes or being in one’s house for no.  While this is certainly more than just glucose metabolism, what does it mean to the person inside?

Still it is quite fascinating that we can look into the brain and while this is not ready for prime time, it suggests that we might be able to someday ask those in a PVS for their opinion on further treatment.  And it may well suggest that the religious imperatives of treatment may be altered as this Chicago Tribune article suggests.

I had a friend who was thrown through a windshield and ended up in a long term coma.  A friend and I came up to visit, and she was lying there kicking in a way that the ICU nurse described as frustrated and angry.  I told her that her estranged father had been there to visit her, and I am quite certain that she heard as she quieted down and seemed to focus.  She started kicking again when we gave her more trivial news.  While she was not in a persistent vegetative state, she was in some middle area.  And when she was told that she would be moved to a facility that specialized in the rehabilitation of comatose young adults, she died that night.

I always believed that she did not want to go through the massive effort that would have been required to regain a life.  Just as my grandmother slipped away the night before the balloon angioplasty she didn’t want was scheduled.

When a friend in her 90s coded and was revived after 25 minutes, the hospital assured us that she had had no oxygen to her brain for far too long to ever revive consciousness.  Outside of the hospital she would have died.  Her family was not present, so she was hooked up to IV nutrients, antibiotics and a ventilator which violently inflated her lungs and kept her body living.  She was loved in her community and we often came by the ICU and sang to her and touched her and I am quite certain that at some level, perhaps limbic, she responded.   But I am also certain that it benefited those of us who wanted to say goodbye more than it benefited her.  I would not want to be in that situation.

It is possible that some day the technology will be cheap enough and advanced enough to be used to make decisions on treatments for those who cannot otherwise communicate.  But that time is not yet at hand and we should consider carefully the implications.  Perhaps instead we should sharpen out intuition and learn to listen to those close to death  in ways that do not involve technology.


NY Times.  Communicating with Those In a Persistent Vegetative State.

Science Daily.  Trawling the Brain.

Wikipedia.  Functional Magnetic Resonance Imaging.

Wikipedia.  Neurogenesis.

Silver Buzz Cafe.  Brain Scanning Technique Offers New Hope for Persistent Vegetative Patients.

“Willful Modulation of Brain Activity in Disorders of Consciousness” – Martin M. Monti, Ph.D., Audrey Vanhaudenhuyse, M.Sc., Martin R. Coleman, Ph.D., Melanie Boly, M.D., John D. Pickard, F.R.C.S., F.Med.Sci., Luaba Tshibanda, M.D., Adrian M. Owen, Ph.D., and Steven Laureys, M.D., Ph.D. – New England Journal of Medicine – February 3, 2010 – 10.1056/NEJMoa0905370.

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