Mistakenly Declared "Brain Dead?"
This story is a bit suspect. It claims that three Japanese nationals were declared "brain dead" in Canada and the USA, but later recovered after being transported back to Japan.
The term "brain dead" is notoriously misused. For example, one of the patients was breathing on his own but was supposedly declared brain dead anyway. NO reputable doctor would declare death by neurological criteria if the patient could breathe independently since, by definition, part of the brain would clearly be working.
What I suspect might have happened is the patients were declared to be in a persistent vegetative state, which some refer inaccurately to as brain dead. Of course, even this diagnosis was apparently wrong, highlighting the problem of rushing to cut off life-sustaining treatment to people with serious and catastrophic brain injuries. It also illustrates the need to establish universal diagnostic criteria that must be followed before doctors can declare death by neurological criteria.
posted by Wesley J. Smith @ 1:41 PM
22 Comments
22 Comments:
PVS - not persistent, not vegetative, and not a particular state.
Bioethics - not biology, not ethical, and not a science.
Yes. I hate the term "vegetative," as no human being is a cucumber. Bioethics can definitely be an oxymoron at times. Thanks.
Thanks yourself.
Worse than equating human life to flora, PVS is a catch basin for bioethical refuse - human lives. I am sure you are very much aware that 53% or so of "PVS" diagnosed patients recover extensively. Medicine has no clue who will recover, and who will not.
I am sure also you have heard that ambien has interesting effects on many patients "diagnosed" (I would claim not diagnosed) as PVS. This was not predicted by medical science. A doctor did not introduce ambien into the PVS patient. It was a mother. The patient regained speaking capability, in brief.
I very much like your characterization of the term bioethics as an oxymoron. I characterize it exactly the same way.
I have blogged on the three Ambien cases. Let's see what else develops along this line. I have quoted the statistic you cited in CULTURE OF DEATH and FORCED EXIT.
Seventh Layer, do you have a source for your claim that "53% or so of "PVS" diagnosed patients recover extensively. Medicine has no clue who will recover, and who will not."
I don't want to buy "Culture of Death" just to find one statistic.
Surely.
PVS patients continue to recover at least partially for up to three years and longer, although recovery after three years is not common. Here is one original study from 1996 producing a recovery rate of 43%. I will find the other original, much larger study which produced the 53% statistic sometime today; this one is only the first one I encountered - Perhaps Wesley Smith has a much more complete bibliography at hand, though!
http://bmj.bmjjournals.com/cgi/content/full/313/7048/13
This article refers to a study producing 52% recovery:
http://www.xenos.org/ministries/crossroads/donal/pvs.htm#Ref17
when PVS in adults was caused by a traumatic injury (e.g. traffic accident), one year later, 33% had died, 15% remained in PVS and 52% recovered consciousness. Of those who recovered consciousness, 54% had severe disability, 33% had moderate disability and 13% had a good recovery.[17]
http://jnnp.bmjjournals.com/cgi/reprint/73/4/355
This article refers to a 54% recovery after one year from traumatically induced PVS.
Pardon my bumbling around . . . there is still more worth reading.
http://gerryroche.com/thesis/Thesisconc.htm
"The assertions that PVS patients lacked consciousness and the ability to experience pain are treated in the literature as being scientific propositions. As such, they are, presumably, open to independent verification, yet the rate of misdiagnosis of PVS (and, by implication, of consciousness[iv]) is close to 50% - the diagnosis of PVS is no more reliable than if made by the tossing of a coin!"
Notwithstanding recovery, the error rate of the intital diagnoses is as high as 37%!
http://home.vicnet.net.au/~borth/PVSILM.HTM
"A 17% error rate is not encouraging, but it is considerably less than the 37% error rate found in the only study addressing the question directly (44), where 18 out of 49 people were found to be inaccurately diagnosed. An error rate of 37% should really be sufficient to dismiss PVS to join hysteria and green sickness in the limbo of dead diagnoses. Perhaps for this reason, that figure appears nowhere in the Consensus Statement."
My apologies for messing up Wesley Smith's otherwise very orderly and very excellent blog!
Winston Jen: So, you haven't read COD,and yet, you gave it a one star disapproval on Amazon as if you had read it. Nice integrity.
The statistic isn't about full recovery. It is about misdiagnosis of PVS, where people who were claimed to be persistently unconscious, were not. It comes out of the UK.
http://home.vicnet.net.au/~borth/PVSILM.HTM
"Two of the basic practical issues with any post-coma patient are "Will they recover?" and "Do they feel pain?" As far as possible, Jennett and Plum's definition removed both questions from the realm of argument by building the qualities of irreversibility and lack of consciousness into the attributes of the condition, and, as the quotation shows, most doctors and virtually all ethicists have from the outset accepted these attributed characteristics without question."
So - if the patient recovers, was the diagnosis simply incorrect?
(We certainly know that Terri Schindler felt pain).
Or is this what we have:
"An error rate of 37% should really be sufficient to dismiss PVS to join hysteria and green sickness in the limbo of dead diagnoses."
(link posted above).
What we do have is a diagnosis with an inherent error rate so high as to render it moot and useless, from the very start.
The diagnosis is ALWAYS wrong.
I have not read COD yet, either, but based on Jen's recommendation, I think I shall!
And the precentage misdiagnosed, as I recall is 43%, not 53%. WJS
In the 1996 study, it was 43%.
The study size was barely adequate.
A later study produced 52 or 54%, based on a more respectable size.
I thought I posted the link earlier; perhaps I did not. I'll go find it. It's quite real.
We are quibbling over hairs. Any diagonsis which requires persistence, and is wrong over 40% of the time, is bilge water. We can think of it as "pop" medicine, or "bioethics".
Well, I failed so far. Here's one at 58%, though . . .
http://purplekangaroopuzzle.blogspot.com/2005/05/calculating-pvs-recovery-statistics.html
Here's the Coma Data Bank article:
Vegetative state after closed-head injury. A Traumatic Coma Data Bank Report
H. S. Levin, C. Saydjari, H. M. Eisenberg, M. Foulkes, L. F. Marshall, R. M. Ruff, J. A. Jane and A. Marmarou
Division of Neurosurgery, University of Texas Medical Branch, Galveston 77550.
To elucidate the clinical course of the vegetative state after severe closed-head injury, the Traumatic Coma Data Bank was analyzed for outcome at the time of discharge from the hospital and after follow-up intervals ranging up to 3 years after injury. Of 650 patients with closed-head injury available for analysis, 93 (14%) were discharged in a vegetative state. In comparison with conscious survivors, patients in a vegetative state sustained more severe closed-head injury as reflected by the Glasgow Coma Scale scores and pupillary findings and more frequently had diffuse injury complicated by swelling or shift in midline structures. Of 84 patients in a vegetative state who provided follow-up data, 41% became conscious by 6 months, 52% regained consciousness by 1 year, and 58% recovered consciousness within the 3-year follow-up interval. A logistic regression failed to identify predictors of recovery from the vegetative state.
Naturally, this is my favorite part:
(the study immediately above).
"A logistic regression failed to identify predictors of recovery from the vegetative state."
In other words, they have not a clue what is going on! The ol' bottom line.
This may have been the exact reference to which I referred (and maybe not):
NEJM -- Late Improvement after Post-Traumatic Vegetative StateWe have much to learn regarding the pathophysiology of the vegetative state, but we do know that 52 percent of patients in a persistent vegetative state ...
content.nejm.org/cgi/content/full/334/18/1201 - Similar pages
New England Journal of Medicine may give me the full text in a few minutes; are you interested?
This 1994 study shows about 54% recovery - it is certainly not the one I seek, and I think it was linked above:
http://home.vicnet.net.au/~borth/PVSILM.HTM
The Multi-Society Task Force consider data on 434 head injury patients and note that
Three months after injury, 33 percent of the patients had recovered consciousness; 67 percent had died or remained in a vegetative state. Recovery had occurred in 46 percent of patients at 6 months and in 52 percent at 12 months. Recovery after 12 months was reported in only 7 of the 434 patients. (Multi-Society Task Force, 1994)
My favorite part - "unquestionably HUNDREDS are treated as PVS, when they are not."
The real number has 4 digits, I think.
Errors in diagnosis have occurred? This hardly counts as full disclosure. Remember, the Statement suggests that 10,000 to 25,000 adults in the USA have been diagnosed as having PVS. At a 17% error rate that would represent 1,700 to 4,250 false positives, at 37% 3,700 to 9,250. However inflated the original estimates were, there are unquestionably hundreds of people in the USA who now are being treated as if they are in PVS when they are not, and any discussion of treatment that omits discussion of this possibility is not being honest with its audience.
http://www.ninds.nih.gov/disorders/tbi/tbi_htr.pdf
"Generally, adults have a 50 percent chance and children a 60 percent chance of recovering [sic] consciousness from a PVS within the first 6 months."
Clearly, the word "persistent" presents a grave etymological challenge to our medical community.
Hi Wesley,
you got yourself a great blog !
I haven't read any of your books yet and apart from Reading 'Whatever happened to the Human race?' by Schaeffer and Koop I am not up to speed on the 'bioethics issue.What would you recommend as a good intro into current thinking?I have a Biology degree -so can understand the basics.
A final question ,coming from one of Seventh Layer's url's ,I notice from thislink:http://bmj.bmjjournals.com/cgi/content/full/313/7048/13
this:'Of the 40 patients diagnosed as being in the vegetative state, 10 (25%) remained vegetative, 13 (33%) slowly emerged from the vegetative state during the rehabilitation programme, and 17 (43%) were considered to have been misdiagnosed as vegetative. The identification of misdiagnosis was more common in the later part of the study period: two were recognised in 1992, one in 1993, four in 1994, and 10 in 1995.'
The change in diagnoses over time is a positive think -but leads me to ask how much diagnosis is down to what is 'fashionable' at the time,are there trends in diagnosis?If so then it could be said that we live in a chrono lottery in terms of diagnosis?Here in the UK we also live with a postal code lottery in terms of health provision.
Thanks, Mike. I think my Culture of Death gives a good overview of current thinking in bioethics. Also, my articles archives which can be linked from the blog.
I think PVS has become a potent symbol, as much as a diagnosis, in the drive in some quarters to dehumanize people woth profound cognitive impairments.
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