NeuroRehabilitation - Volume 19, issue 4

Authors: Gigli, Gian Luigi | Zasler, Nathan David

Article Type: Editorial

DOI: 10.3233/NRE-2004-19401

Citation: NeuroRehabilitation, vol. 19, no. 4, pp. 271-272, 2004

Authors: Pope John Paul II,

Article Type: Other

DOI: 10.3233/NRE-2004-19402

Citation: NeuroRehabilitation, vol. 19, no. 4, pp. 273-275, 2004

Authors: Dorff, Elliot N.

Article Type: Research Article

Abstract: 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. Show more

Keywords: Jewish law, bioethics, vegetative state

DOI: 10.3233/NRE-2004-19403

Citation: NeuroRehabilitation, vol. 19, no. 4, pp. 277-283, 2004

Authors: Zasler, Nathan D.

Article Type: Research Article

Abstract: 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. Show more

Keywords: nomenclature, coma, vegetative state, minimally conscious state

DOI: 10.3233/NRE-2004-19404

Citation: NeuroRehabilitation, vol. 19, no. 4, pp. 285-292, 2004

Authors: Giacino, Joseph T.

Article Type: Research Article

Abstract: 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. Show more

Keywords: vegetative state, minimally conscious state, rehabilitation, practice guidelines

DOI: 10.3233/NRE-2004-19405

Citation: NeuroRehabilitation, vol. 19, no. 4, pp. 293-298, 2004

Authors: Andrews, Keith

Article Type: Research Article

Abstract: 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. Show more

Keywords: vegetative state, ethics, withholding treatment, withdrawing treatment, nutrition and hydration

DOI: 10.3233/NRE-2004-19406

Citation: NeuroRehabilitation, vol. 19, no. 4, pp. 299-304, 2004

Authors: Palazzani, Laura

Article Type: Research Article

Abstract: 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).

Keywords: advance directives, Living Wills, right to die, euthanasia, value of life

DOI: 10.3233/NRE-2004-19407

Citation: NeuroRehabilitation, vol. 19, no. 4, pp. 305-313, 2004

Authors: Gigli, Gian Luigi | Valente, Mariarosaria

Article Type: Research Article

Abstract: 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. Show more

Keywords: vegetative state, nutrition and hydration, bioethics, medical profession, euthanasia

DOI: 10.3233/NRE-2004-19408

Citation: NeuroRehabilitation, vol. 19, no. 4, pp. 315-328, 2004

Authors: Schoenle, Paul W. | Witzke, W.

Article Type: Research Article

Abstract: 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. Show more

Keywords: N400, semantic processing, vegetative state, minimally conscious state, severe brain injury

DOI: 10.3233/NRE-2004-19409

Citation: NeuroRehabilitation, vol. 19, no. 4, pp. 329-334, 2004

Authors: Laureys, Steven

Article Type: Research Article

Abstract: 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. Show more

Keywords: positron emission tomography, functional magnetic resonance imaging, consciousness, vegetative state, minimally conscious state

DOI: 10.3233/NRE-2004-19410

Citation: NeuroRehabilitation, vol. 19, no. 4, pp. 335-341, 2004