NRL News
Page 17
February/March 2010
Volume 37
Issue 2-3

NEJM Study Offers More Proof Brain-Injured Patients
Often Misdiagnosed, Undervalued

BY Dave Andrusko

Researchers in Britain and Belgium have offered “a study to rekindle debate over life-sustaining care for those with grievous brain injuries,” finding that some “patients thought to be in a persistent vegetative state showed brain activity indicating awareness, intent and, in at least one case, a wish to communicate,” the Los Angeles Times has reported.

In a study posted online by the New England Journal of Medicine (NEJM), four of 23 patients “diagnosed as being in a vegetative state showed signs of consciousness on brain-imaging tests,” according to the Wall Street Journal’s Amy Dockser Marcus. “Even more significantly, one patient was able to answer yes and no questions using the researchers’ technique—indicating the potential for communication with people previously considered unresponsive.”

Joseph J. Fins, chief of the medical ethics division at Weill Cornell Medical College, New York, who was not involved in this study, told Marcus, “There has been a kind of nihilism towards these patients. This represents a cultural shift.”

The latter sentiment is most likely an exaggeration. But it is clear, as Marcus wrote, “The study is part of a growing body of work changing how people think about the vegetative state.”

Dr. Adrian Owen is one of the co-authors of the research. The study built on earlier work by Owen and his colleagues.

In 2006, a young woman—thought to be in a vegetative state—was placed in a functional magnetic resonance imaging scanner and asked to imagine herself exploring her home or playing tennis. As the New York Times described it, “When doctors asked her to think of playing tennis, areas of her motor cortex leapt to life. When asked to think of being in her house, spatial areas in the brain became active.”

Owen and researchers at the University of Liege in Belgium then heard from many other families eager to see if their own loved one would respond. The study discusses what they found in the first 54 patients. Twenty-three had been diagnosed as being in a “vegetative state” while the diagnosis of 31 was minimal consciousness.

The idea was to compare the patients’ responses with how the brains of normal volunteers put in the fMRIs fired up when asked to imagine themselves hitting a tennis ball or exploring their house room by room. (The fMRI technique highlights areas of the brain that receive increased blood flow when in use.)

Five of the patients responded identically to normal volunteers. Four had been diagnosed as being in a vegetative state; one was thought to be minimally conscious.

The more sensational headlines found in some accounts—“‘Vegetative state’ man responds to questions,” as CNN put it—talked about what happened next. Researchers tried to communicate with one patient, a 29-year-old man in Belgium. They asked him to associate thought about tennis with “yes,” and thoughts of touring his house with “no.”

He was then asked a series of yes/no questions about his life (e.g., his name). To be sure the patient was making conscious decisions, they switched the associations (e.g., “no” with tennis). He got them all right!

“He could produce no communication with his body,” Owen told the Washington Post. “But he could systematically and repeatedly change his brain activity to indicate yes or no with 100 percent accuracy.”

Owen told CNN, “Not only did these scans tell us that the patient was not in a vegetative state but, more importantly, for the first time in five years, it provided the patient with a way of communicating his thoughts to the outside world.”

The NEJM study came “two months after a Belgian car crash victim whose condition was misdiagnosed as a vegetative state for 23 years was revealed to have been conscious the whole time,” wrote CNN’s Peter Wilkinson (see www.nrlc.org/News_and_Views/Nov09/nv112309part2.html).

At a minimum the recent research has thrown into question “the current bedside test for diagnosing mental state: checking whether patients’ eyes can track objects, and carefully looking for any signs—eye blinks, finger twitches—in response to questions or commands,” according to the New York Times. That’s part of the good news.

Of course, as is always the case, some responded by asking whether this might open a channel to inquire whether the person wanted to die! Others said this awareness applied only to a certain category of people with severe brain injuries, and certainly not Terri Schiavo!

Bioethicist Wesley J. Smith noted how every time such research is published, we are told somehow Terri’s case is “different.” On his blog he responded in two ways.

First, referring to the autopsy performed on Terri, Smith noted, “The report said her brain was consistent with either a PVS or minimally consciousness, and moreover, that such decisions are clinical, not subject to being decided upon autopsy.”

Second, as Smith keenly observed, “But this is the point. Conscious or unconscious, people should not have to earn the right to receive basic sustenance. What we did to Terri Schiavo was a blight on the legal system and bioethics. Pretending otherwise won’t make that stain go away.”