CAN UNCONSCIOUS PATIENTS WAKE UP?
In the wake of the discovery (reported in last week's BioEdge) that a brain-damaged woman in the UK in a persistent vegetative state was responding to stimuli, other stories about recoveries from irreversible comas are emerging in the press. While many doctors are sceptical, the possibility that some therapies may restore some consciousness in some cases threatens to overthrow a consensus on how to deal with patients languishing in hospitals and nursing homes. Bioethicist Joseph Fins, of Cornell's Weill Medical College, says that ever since the Karen Ann Quinlan case in the US in the 1970s, doctors have been abandoning brain-damaged patients too readily. As a result, fewer patients improve and the statistics get worse. Then families and doctors give up and researchers stop pursing new treatments. It becomes a vicious circle which Fins dubs therapeutic nihilism. "We've spent a long time allowing people to die," he says. Maybe they deserve more intellectual, diagnostic and therapeutic engagement than we have acknowledged." One simple therapy which has produced remarkable results comes from South Africa: a sleeping pill. A family doctor near Johannesburg discovered that when some severely brain-damaged patients are given zolpidem they emerge from their comas and begin to communicate. No one understands why, but it appears that the damaged brain cells are not dead, in some cases at least, but only hibernating. The drug may wake them up.
A journalist for the UK Guardian met several patients who emerge from a persistent vegetative state after taking zolpidem. The degree of recovery varies, and lasts only about two and a quarter hours, but some of the recoveries appear remarkable. Papers describing what happens have been published in the journals NeuroRehabilitation and the New England Journal of Medicine and a British company, ReGen Therapeutics, is carrying out clinical trials. Another therapy is electrical stimulation of the brain. An American doctor, Edwin Cooper, claims that people given electrical stimulation emerge from comas more quickly and regain functions more quickly than if they are given only traditional treatment. His work has not attracted much attention in the US and was even denounced by the recently deceased expert witness in the Terri Schiavo case, Ronald Cranford, as "junk science".
However, in Japan, electrical stimulation is far more common. Doctors there implant electrodes directly into the spine. The results are not spectacular, but they are significant. About 40% of patients move from a persistent vegetative state to a minimally conscious state. Small as this may seem, relatives regard it as a blessing. Even if these treatments are only experimental, if they can be verified, their implications for end-of-life treatment are enormous. If a persistent vegetative state is no longer a hopeless and irreversible condition, it will become more difficult to justify withdrawing life support from patients. ~ Wired, Sept 6; Guardian, Sept 12
