"Latest research raises important ethical issues concerning our care for patients with chronic consciousness disorders," said Professor Gustave Moonen (Liege, Belgium), past president of the European Neurological Society (ENS), at a press conference at the current ENS Congress. This major meeting in European neurology is gathering more than 2,900 experts from all over the world in Milan. "This is all the more important as studies have shown that more than a third of patients given an initial diagnosis of vegetative state or persistent vegetative state show minimal signs of consciousness under more detailed examination."

230,000 coma patients in Europe per year

The special challenge for neurologists and other professionals caring for coma patients will be just one of the topics under discussion at the congress in Milan. Modern medical progress leads to an increasing number of patients having survived injuries and illnesses but at the price of serious brain injuries. Experts estimate that there are around 230,000 coma patients in Europe each year and that around 30,000 remain in a persistent vegetative state. Many of the studies on coma and related issues are a result of the work done in Liege by the "Coma Science Group" headed by Professor Steven Laureys.

A particularly delicate issue: coma and other states of impaired consciousness are not always easy to differentiate, although the classification can have grave repercussions. Patients seldom remain longer than two to five weeks in a coma, a state of deep unconsciousness uninterrupted by exterior stimuli. The vegetative state is characterized by wakefulness without awareness. "In a chronic vegetative state of more than a year, medical guidelines consider the withdrawal of treatment such as artificial nutrition and hydration ethically justifiable," Prof. Moonen explains. "The minimally conscious state characterizes patients with more than reflex behavior, with an inconsistent but clearly discernible evidence of consciousness but a lack of interactive communication. There are no generally accepted standards for the care of these patients." European studies show varying standards for care and decision making involving passive assisted death.

In a current study being presented at the ENS Congress in Milan, Professors Moonen and Laureys and their team surveyed the attitudes of European doctors, paramedical professionals and non-medical professionals on end-of life decisions in these challenging patients. The investigation shows that that key questions are being evaluated with anything but uniformity. Some 65 % of all respondents considered it acceptable to stop artificial nutrition and hydration in patients in a chronic vegetative state, whereas only 29 % considered this measure justified in patients in chronically minimally conscious states. The majority (78%) of respondents considered that being in a permanent vegetative state is worse than death for the patient's family, but only 51 % think that it is worse than death for the patients themselves. Furthermore, half of the respondents (52 %) considered that being in a minimally conscious state is worse than a vegetative state for the patients. "There are quite different attitudes throughout Europe towards patients in a minimally conscious state and a vegetative state," Professor Moonen points out. "In light of the high rates of diagnostic error in these patients, the necessity for adapted standards of care for minimally conscious state as compared to vegetative state is warranted."

Children with "locked-in-syndrome"

Another new study being presented in Milan by the Coma Science Group identifies the particular problems entailed in the treatment of children with so-called "locked-in-syndrome" (LIS). Patients suffering this syndrome are fully conscious but are completely paralyzed and only able to communicate via small eye movements. "The development of intensive care has considerably increased the number of children surviving acute brainstem damage," Professor Moonen explains. "But LIS is still rare in children. As a result, the diagnosis is often missed or delayed." Researchers in Liege examined a series of five cases. "Two of the reported cases died, and three survived, one up to eleven years, remaining with a severely handicapped motricity but meaningful self-scored quality of life," Professor Laureys reports. "We also observed that most pediatric LIS patients show some motor recovery. Our reported and reviewed data stress the need for physicians to carefully interpret signs and symptoms of LIS." Results of this study are to appear in the journal "Pediatric Neurology".

Neural networks show significant differences between the vegetative state and brain death.

Still another study in Liege shows just how delicate the decision over life and death can be. Through magnetic resonance imaging, the connections among defined neuroanatomical networks in the brain were compared using healthy people, patients in a vegetative state and brain dead patients. "Our MRI data indeed showed not only significant remaining correlations between distant default network areas in a case of vegetative state. In the vegetative state patient, as in age-matched controls, anti-correlations could also be observed between specific cortical networks. Both correlations and anti-correlations were significantly reduced in vegetative state as compared to healthy persons. A similar approach in a brain dead patient did not show any such long-distance functional connectivity," Prof. Laureys explains. "Ongoing multi-centric studies are documenting the diagnostic and prognostic value of cerebral 'resting state' functional MRI studies in coma survivors." Results of this study are in press in the journal "Human Brain Mapping".

Source
European Neurological Society