Awakenings: The possible futures of PVS
So i saw an article in Wired last week that nearly blew my mind--a doctor in the States has been applying electricity to the arms of patients in persistent vegitative states (PVS), which seems to have caused everything from improvement (more movement) to full-blown, if not 100% back to normal, recovery. While the article only interviews one patient who's woken up, it's pretty interesting to see how far she seems to have come. Apparently, there are scientists in Japan who have taken it up a notch and are applying electrodes directly to the spine, leading to improvement in patients' level of consciousness.
Today i stumbled across an article in the Guardian about how patients in PVS have been given zolpidem--also known in the US as commonly used sleeping aid Ambien--and patients have been "waking up" from PVS.
The Ambien article is more compelling, in my opinion. First, it seems that while the electrode therapy has a decently high rate of getting people to move--one patient described began smacking his lips after the electrodes were implanted--only one patient seems to have regained a somewhat normal level of functioning. In her case, since she was only comatose for a couple of months, it's possible that she simply recovered on her own, and the electrical stimulation only causes muscular stimulation. The Ambien effect, on the other hand, has been witnessed by the author and seems to improve patients' Glasgow Coma Scale score. It also seems to have a better effect on patients suffering from anoxic brain injury (lack of oxygen to the brain, basically), whereas the electrode one doesn't seem to show any improvement to patients with anoxic injury.
Both articles are worth reading, and both concepts are, frankly, terrifying. I mean, don't get me wrong--it will be fantastic news to find out that PVS isn't a (near-)death sentence and that there's hope for recovery for patients with traumatic brain injury. But it rips open some rather disturbing issues.
The easiest one is the one raised by the Wired article--these aren't new, instant cures for PVS. Patients *are* improving, but these therapies may give the patients and their families false hope. These patients aren't jumping out of bed three seconds after getting treated to go do cartwheels in the hallway. "Most of the implant recipients, he says, move up a notch in their level of consciousness, from a persistent vegetative state to a 'minimally conscious state,' a condition in which people are able to muster small but unmistakable signs of awareness. 'Maybe the patient just smiles or follows with their eyes,' Kanno says. Other Japanese doctors using deep brain stimulation - in which electrodes are implanted directly in brain tissue - have reported similar results: patients who improve to the point where they are severely disabled rather than entirely unresponsive." [Greenberg, 2006] A "minimally conscious state" means that you still have a patient who needs a lot of care, and who's almost definitely an incredible burden on his or her family or the state (regardless of whether or not they view it that way), and there are a lot of people who take the view that it's more ethical to relieve those people of their burden than to expect them to care for someone who may never do more than smack his lips.
The more chilling concern, however, is the fact that we have been assuming that people in PVS are unrecoverable, and have been pulling the plug (or the feeding tube, or...) on them in the assumption that it's the more humane thing to do. It may be easy for those of us who have never had to make the decision about a patient--not just a patient, but a family member or a partner--to relegate the (dare i say it?) Terri Schiavos of the world to the same category as people who used to be buried alive because we didn't have the technology available to detect death. That's a small comfort, however, to someone who made the decision to pull the plug on her husband, or mother, or child.
There's quite a bit that we don't know about the human body, especially the brain. There are quite a lot of things in medicine that we'll ultimately come to regret. In our defense, most of those things were done out of the belief that they were the right thing (although at times, they were instead done because it was the easy thing). But that's cold comfort to someone who now has to wonder whether or not there was hope for their loved one.
Anyway, it's interesting and fantastic and terrifying news, all rolled into one. I'm intrigued to see where the Ambien trials go and how (if) this revolutionizes the treatment of patients with traumatic brain injury. And, of course, i'm interested to see what you all think.
ETA: I thought i'd drop the links in here just to make them easier to find.
Wired article: http://www.wired.com/wired/archive/14.09/brainshock_pr.html
Guardian article: http://www.guardian.co.uk/medicine/story/0,,1870279,00.html
Today i stumbled across an article in the Guardian about how patients in PVS have been given zolpidem--also known in the US as commonly used sleeping aid Ambien--and patients have been "waking up" from PVS.
The Ambien article is more compelling, in my opinion. First, it seems that while the electrode therapy has a decently high rate of getting people to move--one patient described began smacking his lips after the electrodes were implanted--only one patient seems to have regained a somewhat normal level of functioning. In her case, since she was only comatose for a couple of months, it's possible that she simply recovered on her own, and the electrical stimulation only causes muscular stimulation. The Ambien effect, on the other hand, has been witnessed by the author and seems to improve patients' Glasgow Coma Scale score. It also seems to have a better effect on patients suffering from anoxic brain injury (lack of oxygen to the brain, basically), whereas the electrode one doesn't seem to show any improvement to patients with anoxic injury.
Both articles are worth reading, and both concepts are, frankly, terrifying. I mean, don't get me wrong--it will be fantastic news to find out that PVS isn't a (near-)death sentence and that there's hope for recovery for patients with traumatic brain injury. But it rips open some rather disturbing issues.
The easiest one is the one raised by the Wired article--these aren't new, instant cures for PVS. Patients *are* improving, but these therapies may give the patients and their families false hope. These patients aren't jumping out of bed three seconds after getting treated to go do cartwheels in the hallway. "Most of the implant recipients, he says, move up a notch in their level of consciousness, from a persistent vegetative state to a 'minimally conscious state,' a condition in which people are able to muster small but unmistakable signs of awareness. 'Maybe the patient just smiles or follows with their eyes,' Kanno says. Other Japanese doctors using deep brain stimulation - in which electrodes are implanted directly in brain tissue - have reported similar results: patients who improve to the point where they are severely disabled rather than entirely unresponsive." [Greenberg, 2006] A "minimally conscious state" means that you still have a patient who needs a lot of care, and who's almost definitely an incredible burden on his or her family or the state (regardless of whether or not they view it that way), and there are a lot of people who take the view that it's more ethical to relieve those people of their burden than to expect them to care for someone who may never do more than smack his lips.
The more chilling concern, however, is the fact that we have been assuming that people in PVS are unrecoverable, and have been pulling the plug (or the feeding tube, or...) on them in the assumption that it's the more humane thing to do. It may be easy for those of us who have never had to make the decision about a patient--not just a patient, but a family member or a partner--to relegate the (dare i say it?) Terri Schiavos of the world to the same category as people who used to be buried alive because we didn't have the technology available to detect death. That's a small comfort, however, to someone who made the decision to pull the plug on her husband, or mother, or child.
There's quite a bit that we don't know about the human body, especially the brain. There are quite a lot of things in medicine that we'll ultimately come to regret. In our defense, most of those things were done out of the belief that they were the right thing (although at times, they were instead done because it was the easy thing). But that's cold comfort to someone who now has to wonder whether or not there was hope for their loved one.
Anyway, it's interesting and fantastic and terrifying news, all rolled into one. I'm intrigued to see where the Ambien trials go and how (if) this revolutionizes the treatment of patients with traumatic brain injury. And, of course, i'm interested to see what you all think.
ETA: I thought i'd drop the links in here just to make them easier to find.
Wired article: http://www.wired.com/wired/archive/14.09/brainshock_pr.html
Guardian article: http://www.guardian.co.uk/medicine/story/0,,1870279,00.html