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The persistence of mind
THE LANCET
THE LANCET Volume 348, Number 9020 EDITORIAL
The persistence of mind The term persistent vegetative state (PVS) was first proposed by Bryan Jennett and Fred Plum in The Lancet in 1972 to describe brain-injured patients who emerge from coma and seem awake but who show no sign that they are aware of themselves or their surroundings. Since Jennett and Plum’s paper, there has been little change to this definition, and despite the emergence of new neuroimaging techniques, the diagnosis continues to be made mainly at the bedside, by history, physical examination, and careful observation over time. The debate instead has focused on when it is reasonable to assume that a patient with PVS has no hope of recovery and whether it is appropriate to withhold life-saving or withdraw life-sustaining treatments. Generally, physicians have held that these clinical decisions should be made by the patient’s doctors in consultation with the family and in accordance with certain guidelines. But two papers, both of which appeared last week (one in this journal and the other in the BMJ), threaten to undermine the public’s confidence that physicians are to be trusted to make these treatment decisions without more legal oversight. In The Lancet, Prof Andrew Grubb and colleagues reported a survey of consultants in specialties that frequently involve the care of patients with severe brain injuries. More than two-thirds of respondents held that the decision to withdraw artificial nutrition and hydration should be left to doctors in consultation with family members and following agreed guidelines. But the doctors’ answers to other parts of the survey raised the question of which guidelines, if any, should be followed. Two-thirds of the doctors said that they thought it was appropriate to consider withholding treatment before 12 months, and nearly half thought it was appropriate within 6 months. These answers conflict with PVS treatment guidelines issued by the British Medical Association in 1993 and the legal ruling of the UK House of Lords in the Tony Bland case. Moreover, the respondents said that in making Vol 348 • July 13, 1996
such decisions they would give more weight to the length of time the patient was in a vegetative state than to the cause of the brain injury or age, despite the fact that these factors are regarded in the guidelines prepared by the BMA and by the American College of Neurology as being important when deciding, during the first 12 months after a brain injury, if a vegetative state is permanent. But even more surprising was the finding that only 39% of the consultants considered that an advance directive by the patient should have a decisive influence in a decision to withdraw artificial nutrition and hydration. The findings of Keith Andrews et al in the BMJ are even more worrisome. In that series of patients, 17 out of 40 individuals referred to London’s Royal Hospital for Neurodisability with the diagnosis of PVS were found to have been misdiagnosed and were, in fact, aware. Seven of these patients had been presumed by their caregivers to be in a vegetative state for longer than a year, including three for over four years. Rightly or wrongly, the findings from both papers are likely to be cited as reasons for legislation to increase the regulation and judicial supervision of doctors’ decisions in the treatment of not only PVS but also other severe brain injuries. It is incumbent on physicians to take steps to reassure the public that they are indeed competent to make these decisions independently and that they are aware of and adhere to professional guidelines and legal requirements, such as those that mandate they honour their patients’ advance directives. If additional studies confirm Andrews’ findings that there is an unacceptably high rate of misdiagnosis of PVS with current clinical techniques, new research will be needed to develop methods, such as positron-emission tomography, that may be able to diagnose more reliably the vegetative state and predict a patient’s chances of recovery.
The Lancet 69
THE LANCET Volume 348, Number 9020 EDITORIAL
The persistence of mind The term persistent vegetative state (PVS) was first proposed by Bryan Jennett and Fred Plum in The Lancet in 1972 to describe brain-injured patients who emerge from coma and seem awake but who show no sign that they are aware of themselves or their surroundings. Since Jennett and Plum’s paper, there has been little change to this definition, and despite the emergence of new neuroimaging techniques, the diagnosis continues to be made mainly at the bedside, by history, physical examination, and careful observation over time. The debate instead has focused on when it is reasonable to assume that a patient with PVS has no hope of recovery and whether it is appropriate to withhold life-saving or withdraw life-sustaining treatments. Generally, physicians have held that these clinical decisions should be made by the patient’s doctors in consultation with the family and in accordance with certain guidelines. But two papers, both of which appeared last week (one in this journal and the other in the BMJ), threaten to undermine the public’s confidence that physicians are to be trusted to make these treatment decisions without more legal oversight. In The Lancet, Prof Andrew Grubb and colleagues reported a survey of consultants in specialties that frequently involve the care of patients with severe brain injuries. More than two-thirds of respondents held that the decision to withdraw artificial nutrition and hydration should be left to doctors in consultation with family members and following agreed guidelines. But the doctors’ answers to other parts of the survey raised the question of which guidelines, if any, should be followed. Two-thirds of the doctors said that they thought it was appropriate to consider withholding treatment before 12 months, and nearly half thought it was appropriate within 6 months. These answers conflict with PVS treatment guidelines issued by the British Medical Association in 1993 and the legal ruling of the UK House of Lords in the Tony Bland case. Moreover, the respondents said that in making Vol 348 • July 13, 1996
such decisions they would give more weight to the length of time the patient was in a vegetative state than to the cause of the brain injury or age, despite the fact that these factors are regarded in the guidelines prepared by the BMA and by the American College of Neurology as being important when deciding, during the first 12 months after a brain injury, if a vegetative state is permanent. But even more surprising was the finding that only 39% of the consultants considered that an advance directive by the patient should have a decisive influence in a decision to withdraw artificial nutrition and hydration. The findings of Keith Andrews et al in the BMJ are even more worrisome. In that series of patients, 17 out of 40 individuals referred to London’s Royal Hospital for Neurodisability with the diagnosis of PVS were found to have been misdiagnosed and were, in fact, aware. Seven of these patients had been presumed by their caregivers to be in a vegetative state for longer than a year, including three for over four years. Rightly or wrongly, the findings from both papers are likely to be cited as reasons for legislation to increase the regulation and judicial supervision of doctors’ decisions in the treatment of not only PVS but also other severe brain injuries. It is incumbent on physicians to take steps to reassure the public that they are indeed competent to make these decisions independently and that they are aware of and adhere to professional guidelines and legal requirements, such as those that mandate they honour their patients’ advance directives. If additional studies confirm Andrews’ findings that there is an unacceptably high rate of misdiagnosis of PVS with current clinical techniques, new research will be needed to develop methods, such as positron-emission tomography, that may be able to diagnose more reliably the vegetative state and predict a patient’s chances of recovery.
The Lancet 69