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Miscellaneous thoughts and ramblings
Thursday, March 24, 2005
 
British Medical Journal: New technique helps to assess vegetative state
British Medical Journal: New technique helps to assess vegetative state

"In 1996 a study showed that after assessment with SMART 43% of the patients who had been admitted to the brain injury unit and believed to be in a vegetative state had been wrongly diagnosed (BMJ 1996; 313:13-6)."


Authors: Wilson SL. Gill-Thwaites H.

Institution: University of Glasgow, Department of Psychological Medicine,
Gartnavel Royal Hospital, UK. email: s.l.wilson@clinmed.gla.ac.uk

Title: "Early indication of emergence from vegetative state derived from
assessments with the SMART--a preliminary report."

Updated to add Further reading:

You'll obviously need access to the journals to read the full articles.


---------
Published in: Brain Injury. 14(4):319-31, 2000 Apr.

Abstract:
"An explanatory analysis of data from serial assessments of 30 patients with a
diagnosis of vegetative state (persistent vegetative state) was carried out.
The data were gathered using the Sensory Modality Assessment and Rehabilitation Test. It was found that those who emerged later could be differentiated
mathematically from those who did not emerge, using largest recovery score
data from the SMART. This research supports previous..."

---------


Authors: Wilson SL. Gill-Thwaites H.

Institution: University of Glasgow, Department of Psychological Medicine,
Gartnavel Royal Hospital, UK.

Title: "Early indication of emergence from vegetative state derived from
assessments with the SMART--a preliminary report."

Published in: Brain Injury. 14(4):319-31, 2000 Apr.

Abstract:
"An explanatory analysis of data from serial assessments of 30 patients with a
diagnosis of vegetative state (persistent vegetative state) was carried out.
The data were gathered using the Sensory Modality Assessment and Rehabilitation Test. It was found that those who emerged later could be differentiated
mathematically from those who did not emerge, using largest recovery score
data from the SMART. This research supports previous..."

---------

"Our preliminary results suggest that SPECT can improve both the knowledge of a patient's neurological conditions and management in comparison to the use of only CT scan." (SPECT, like PET, is a nuclear-imaging technique.)

Authors: Facco E. Munari M. Behr AU. Baratto BF. Zucchetta P. Bui F. Cesaro S.
Giron GP.

Institution: Department of Anesthesiology and Intensive Care, University of
Padua, Italy.

Title: Assessment of brain perfusion in coma and comparison between SPECT and
CT scan data: preliminary report."

Published in: Neurological Research. 20 Suppl 1:S40-3, 1998.

Abstract:
"In this study we submitted 24 comatose patients (Glasgow Coma Score <8)
to Single Photon Emission Tomography (SPECT) during the clinical course of
coma to verify its utility and the relationship between SPECT and CT scan data. SPECT allowed us to recognize different regional flow patterns, such as
absolute or relative hyperemia or oligoemia, which could not be checked with
other means, thus improving patient's management. Apart from cerebral
ischemia, there was no relationship between lesions on CT-scan and flow pattern. Our preliminary results suggest that SPECT can improve both the
knowledge of patient's neurological conditions and management in comparison to
the use of only CT scan."
Comments:
Whhoooaaaaaaaa. Don't you go bringing that science stuff into this debate. What are you, some sort of intellectual?

Persistant vegetative state is a clinical diagnosis, in other words, established by observation. Imaging studies, such as spect, pet, mri, ct, etc, can establish that the imaging is possibly consistant with pvs, but cannot diagnose pvs. Also, with functional tests like spect and fMRI, you can get results that you dont know how to analyze. For example, if you shine a light in someone's eyes, and you see activity in the occipital cortex, is that just the light being automatically processed where it usually is processed, or does it mean that there is consciousness? Dont get me wrong, I think testing is great and more studies should be done, but the studies themselves are open to interpretation. Also, there is a big difference between predicting who at 2 weeks status post brain injury is going to recover, and establishing pvs in someone 15 years post brain injury.
 
Fair points, Dilbert, but it sounds like we both agree that -- ignoring the legal brick wall for the moment -- Terri Schiavo wouldn't be hurt by allowing these tests. Any diagnosis (including the clinical one offered in the Schiavo case) is open to some interpretation. It's why we watch "House". Having all REASONABLY gathered information seems to be only due diligence.

From Bean's comment in this thread, it sounds that there is some dispute on how much of her cerebral cortex (if any) is left, and how functional whatever may be left is. Seems to me that MRI and PET could yield some insight into this beyond what CT has offered.

Given the stakes (life/death), due diligence would seem to be the minimum ethical standard.
 
In an effort to defragment the conversation I hereby make this our only live commenting thread on the Schiavo story and will put comments to that effect on the other threads. Got something to say? Say it here.
 
No, there's no dispute about how functional her brain is. Some doctors said all her cortex is gone, others said almost all of her cortex is gone. An MRI will just help take really cool pictures of her brain. It won't say anything about recovery. Most brain recovery after injury happens in the first few months. She's had 15 years. She's not going to get any better.

Dilbert: thank you for taking the time to comment here. From a brief glance at your group blog it looks like I need to help you understand how the free marketplace can help medicine, but that's for another time. Meanwhile, on this horrible issue, I appreciate your help.
 
Bean,

The bigger issue than how much recovery she can experience is how much (if any) consciousness she has now. I take it that you're saying that if all of her cerebral is gone, she has none. For discussion purpose, I'll accept that on face value. I'm also taking you to be saying that if some of her cerebral cortex is there, she may have some consciousness. An MRI could help to determine the status of her cerebral cortex (I think), and a PET scan could provide insight into what kind of activity is going on in there.

Again, what harm would these tests do? Should we not be as sure as possible before ending a life.
 
Nomad: How much consciousness she has now can be determined clinically (i.e. by a neurologist examining her). Imaging testing is not necessary for that. I don't object to further testing, but I also don't think it's required, and most importantly, I'm not her guardian. Her court appointed guardians (she's had 3) have also not thought more testing is needed.

What should the rule be? Should more testing be done as long as anyone in the country thinks it's necessary? As long as someone in the family thinks it's necessary?

Moreover, I'm drunk.
 
Her primary guardian suffers from a clear conflict of interest. He didn't remember her "wishes" until over 4 years after she found herself in this condition.

I too am moderately inebriated. Earlier tonight, I had a few margaritas with a good friend who happens to be liberal. I was dreading this topic coming up because I didn't want to disagree with a friend on something.

She surprised me by being pretty much on the same side. One thing that stands out: despite wanting to die if in a state like Terri's, she expressed anger at Michael Schiavo for putting Terri's parents through this. She made the point that, even if she wanted not to be left in this state, she would want even less for her parents to be put through what Terri's parents have. In other words... kill me, but if it breaks my mother's heart to kill me, keep me alive.

Maybe it doesn't change the immediate legal issues, but it should be food for thought. I've sat here and watched a girl's parents be forbidden from caring for her while she dies. I've watched the lawyer for a man who was married to her for 7 of her forty plus years tell us that anyone who disagrees with her being starved to death is analagous to the Soviets.

I return to the same principles. Her wishes are definitely not known. Her condition is in dispute. What good reason can anyone provide me for killing her until these issues are resolved satisfactorally?
 
I hear you. I don't think I have an answer that doesn't involve repeating what I've already said.

As a tangent, I've had lots of patients give conditional answers like your friend (or their families give them for the patients). "Joe would want the ventilator removed, but he always wanted to see his aunt Betty from Ohio again, so if she's willing to fly down to the hospital, he'd want to stay on the ventilator until she was with him." Stuff like that. I always found that touching and always did my best to accommodate those wishes. So I've kept a dying man in the ICU for a few days while the family scrambles to get Betty into town. Of course, it turns out Betty hasn't traveled in years because she has some mild dementia and can't possibly book a flight or get to the airport on her own, but after some false starts (including an urgent letter faxed from me to the travel agent asking that the original tickets be refunded) the family arranges everything and she makes it. And it's worth it, because the family is left knowing that they did what Joe would have wanted.
 
I hate having to repeat myself, but here goes....the courts and the doctors who have examined her and her legal guardians all agree that she wouldn't want to live like "this" meaning pvs or close to it. Nomad, I love you but you are not a neurologist. You and I are never going to sort out how much of her cerebral cortex is there. I am willing to trust the multiple doctors who have seen her. You want more tests. Has anybody but me considered the possibility that Michael Schiavo is the hero in this? It appears from recent interviews I have seen that her family believes she is "merely disabled." Her brother actually said that if they put her in a wheelchair, they could take her to the movies or to a ball-game. How delusional is that? You could put a corpse in a wheelchair and take it to a ball-game! So? The family, therefore, believes that she would *enjoy* the ball-game and that is insane. I heard her brother-in-law this morning saying that since Terri is fading, they have to listen very hard to hear her voice. Her voice? No-one (except that nutty nurse) believes that she speaks. The family is merely holding on to the falsehood that she is "in there." I suspect that Michael Schiavo is the hero for insisting upon what Terri wants and not being deluded about her mental status. It is too bad that he is the villain in this.
 
This really rests on Terri's wishes. Sure all of her guardians agree on those wishes. All of her guardians are Michael Schiavo.

In order to accept that Michael is the hero in this case, you would also have to question why our hero allowed his wife to be kept in such a condition for 8 years before remembering the casual comments she made in the 1980s?

He MAY be the hero. He also MAY be acting entirely on his own beliefs and/or personal wishes.

As to her condition, I hate to repeat myself, but 33 medical professionals (including 15 neurologists) have signed affidavits contending that Terri's condition should be reevaluated.

Putting that aside, however, it really comes back to Terri's wishes. There's ample reason to doubt the husband's motives after 8 years of not acting on what he now claims he knew to be her wishes. Everyone else in her family, including the man and woman that conceived, gave birth to and raised her disagrees with him.

It sounds to me like you are willing to declare her life (and by extension, presumably, the lives of others who have severely impared mental faculty) unfit to live, even in the absense of her known wishes.

I'm not prepared for us, as a society, to jump off that moral cliff.

Bottom line. If her wishes were known, they should have been carried out over a decade ago. They are not known. She should have been allowed to live.
 
I don’t think you’d much like this posting: http://ninescorpions.blogspot.com/but I thought I’d share it anyway. He, while responding to a blog that I wrote in favor of there being a congressional responsibility to help Terri, finishes with calling her an “it". The sentiment that we have a right to determine what quality of life someone would want and refering to other living beings as "it" is what Terri's family is fighting against.
 
Nomad: Your questions in this post in the tone of opening a reasonable discussion, basically asks whether 4 completely basic points of either medical ethics or law should be overturned. Let me paste each one below and try to answer.

--Is food and water delivered through a tube extraordinary medical intervention, or is it basic care?
Well, this has already been answered by standard medical ethics, but your question is really "shouldn't we revisit that question?" Fair enough, but think for a moment the consequences of deciding that food through a feeding tube is basic care that one can not refuse even if informed. Patients would be much more hesitant to get a feeding tube because they would be making an irreversible decision. What was before a simple consent to a simple procedure for potentially short term feedings, now becomes an agonizing choice in which permanent disability and unwanted tube feedings must be considered. "The doctor says I need tube feedings for just two weeks while my swallowing recovers from the stroke, but he says if meanwhile I have another stroke that puts me in a coma, the tube stays forever." People who before would have consented, since they would have retained the option of later refusal, now must refuse before the tube is put in. Would you find that preferable to the current situation? I would not.

--Is allowing a person to die through dehydration an acceptable practice?
Again this is entirely uncontroversial in standard medical ethics. Again, think of what the consequences of reversing this would be. Patients dying of cancer elect to die of dehydration all the time. They don't have tube feeds but they just become too weak to drink and they make it clear that they want only comfort care (i.e. morphine) at that point. People with dementia, and cancer, and end-stage heart disease are allowed to die by dehydration by following their wishes all the time. Would you make it mandatory that I start intravenous fluids on those patients? That would prolong their death until they die of an infection or respiratory failure.

--Should one person be given sole say in determining whether or not a patient should be allowed to die, where other family members are available, and in disagreement?
During the various parts of Terri's case she had more than one court appointed guardian. This was not her husband. It was an unrelated person assigned by the court to act in her interests. Read the time-line summary that I link to in this comment.

--Should appellate courts review evidentiary matters?
I have no clue about law; I just know that that's exactly what they don't do now. Maybe someone with a legal background can tell us the implications of this.

Nomad: Please tell me what you would like to see done in Terri's case specifically. You've mentioned that you think more testing is in order. Fine. Let's imagine that a Federal court orders that she has an MRI and a SPECT. That won't decide anything; it will just postpone a decision. The tests will show a severely damaged brain and then opposite lawyers will argue about the interpretation. We know it won't show a normal brain because a lot of damage was already seen on CT. What then? Should the parents just be given custody of Terri?

I think conservatives (and I don't have to restate how much I love conservatives here) have come to this party way too late and too poorly informed. Whatever questions we have about Terri's case in particular, we have a system that in general works very well, and before tampering with it we should think not only of her, but of all those that will come after her.
 
I'll leave the first two issues and the last one alone for the moment, as I'm on limited time. As for the court appointed guardians, I have a hard time with the fact that they gave the parents no standing. You continually make the point that this should be a family issue. Her parents should be part of the decision-making process. Temporary, court-appointed guardians or not, Michael is the only person who has any say in the matter at this point.

As for Terri's specific case, I think it would be entirely reasonable for her mother and father to be given custody of her. Michael's delay of 8 years in remembering Terri's wishes, and his remarriage (for all intents and purposes other than legal) have disqualified him from being her guardian (to me, if not to the courts).

I wouldn't expect to see a normal brain on an MRI or a PET, but I think the parents (as her guardians) should be allowed those tests to help them and her doctors make decisions. I also don't believe that the criteria (absent a person's known wishes) should be a "normal brain".

I fear making arbitrary decisions about what is a life worth living. I'm sure I don't need to outline the slippery slope argument that causes my unease.

I've got some thoughts on the feeding tube issue, but not time to type them out. I'll just say that removing nourishment and hydration from a person, whether that nourishment/hydration is supplied by a tube or by mouth, feels like it's at the very least, straddling the fence between allowing nature to run its course and euthanzia. I realize the existing medical ethics in this country differ with me on this point. I think it may be worth revisiting.
 
I would also add, re: cancer patients and end-stage heart disease patients, that these are not analogous to the situation we have with Terri Schiavo. Nothing is killing her other than removal of the tube. Her physical condition is otherwise stable.

So, perhaps there should be a distinction between terminally ill patients and patients who have long-term and/or severe handicaps (physical or mental). I haven't thought through the full ramifications of that, but wanted to get it out there while it was fresh in my mind.

Allowing a person who is already on their way out to hasten that death is different from allowing a person whose long-term quality of life is compromised are very different things.

Just as an addendum, you noted 11 days ago that you didn't know how a person could go a week without water. Terry's still alive. Is this the first time you've seen a patient last this long without water? Is it possible that her otherwise healthy physical state has enabled her to go longer than the patients you're more accustomed to seeing, who are already dying of some other cause?
 
"Is it possible that her otherwise healthy physical state has enabled her to go longer than the patients you're more accustomed to seeing, who are already dying of some other cause?"

Yes.
 
By the way, I just confirmed that Michael did/does have money to gain in the event of Terri's death. From the 2nd Guardian ad litem's report PDF VERSION:

"Mr. Schiavo indicated strongly o the undersigned that his petition to withdraw life support has nothing to do with the money held in the guardianship estate, which he would inherit upon the ward's death as her sole heir-at-law."
 
There's way too much contradictory information that's getting thrown around by the media, probably without good fact-checking and actual journalism (which went out a generation ago). The reason I say this is that I've also heard more than once on the radio that the husband has had more than one multi million offer from potential benefactors to divorce Terri and walk away from the case. If it was about the money, why would he still be doing this?

I don't know what to think anymore. I think we're getting bombarded with half-truths and hysteria. If only there was an organized way to have both sides present what they think and then have unbiased people consider both sides fairly and come to a decision...

Oh! That's right, there is! The state courts and the appelate system.

Phewf. I feel a lot better.
 
Nomad: ball-and-chain informs me that Fox News reported that only $40 - $50,000 remain in Terri's account. That doesn't suggest he's doing it for the money.

See what I mean? If there was some serious fact checking going on, with a central repository of information, then maybe I could formulate an opinion that would be worth $0.02. (It would be a perfect thing for a large blog with lot's of fact-checking readers.) But as it is, everyone's got an agenda and everyone thinks one side or the other is Satan.

Lileks comparison of this to the Elian Gonzales case was perfect. Poor Terri had no intention of ending up at the crux of a whole bunch of competing values and conflicting agendas.

I realy don't think I'm going to have much more to say about this very sad case.
 
Bean,

If you had clicked the link, you would have seen that my information didn't come from the media. Rather, I was reading the court documents (the same documents you referenced in an earlier post), and stumbled upon the quote. Nothing conflicted about it. It's part of the official record.

As for why the husband wouldn' take a multimillion dollar payment from someone at this point, I would quote Teddi Bruschki of the New England Patriots, "C'mon now?!" or John McEnroe, "You cannot be serious." Sure, he's going to take a million bucks in front of the billion or so people that are watching, and admit to the entire world that it was about money from the get-go.

I am also aware that most of the money has been burned through at this point. As Hagus (of the movie "Pumpkinhead") said, "it's gotta run its course." At the time he initially tried to allow her to die, it was IMMEDIATELY after the settlement. He stood to gain 700K at that point. I suppose when that money had dwindled down to less than 100K, and he'd spent 10 years of his life in pursuit of this objective, he could have said to the world at large, "okay, it was really about the money, and I don't care now," but again, "c'mon now." Common sense tells you that once so much water is under the bridge these things develop a momentum of their own.

So, back to my point, at the point he launched the suit, he stood to gain a whole buncha cash. I get that not from conflicted media reports, but from a diligent study of the court documents. That the amount has dwindled in the face of her continued existence doesn't remove the question mark above his initial decision, given its tardiness.

Why not sue to have the tube pulled BEFORE winning money for her continued care in court? Because it didn't occur to you prior to the settlement that she'd want to die?

Anyhow, I hope my tone isn't too defensive, but your comment about half truths and hysteria couldn't have been more off-target.
 
And, the miami.edu link where I got the information IS pretty much a central repository of information... at least in terms of the official documents. As noted in the original timeline post, the University of Miami doesn't appear to have a dog in this fight. I'll repost the link for your edification.

Schiavo Resources: Timeline
 
FOXNews is reporting that Terri Schiavo has died.

Requiem aeternam dona eis Domine:
Et lux perpetua luceat eis.


Grant them eternal rest, O Lord:
And let everlasting light shine on them.

-- from Mozart’s Requiem
 
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