Time to pull the plug? Perhaps, perhaps not

[okarol]

Time to pull the plug? Perhaps, perhaps not

Monday, February 15, 2010

By Dr. David L. Katz

A fascinating study published online recently in the New England Journal of Medicine demonstrates that a small percentage of seemingly comatose patients are actually aware of, and responsive to, their environment. Most experts consider the study — which used functional MRI scans to measure brain responses not otherwise detectable — highly significant, and I agree.

There is much about the brain we barely understand, and this becomes a scary liability when the brain function of a loved one is the basis for life-and-death decision making. We don’t routinely have functional MRI to come to our rescue. Fortunately, judgment can function as a surprisingly good proxy.

Such judgment will at times indicate that hope of recovery is so remote that desperate efforts are ill advised. Other times, it will indicate the opposite.

Some years ago, I was on call over the weekend in a walk-in center, and saw a woman in her early 50s, a smoker recently treated for bronchitis, with a sore throat that came on at the tail end of that illness. There wasn’t much remarkable about her case, and I sent her home with some garden-variety recommendations and advice to return if not improving.

Return she did, within 48 hours. When I saw her the second time, her throat was not just inflamed — she had signs of hemorrhaging into her tonsils. I ordered blood work, and the results were as appalling as they could be: She had acute leukemia.

I shared the news as best I could with the patient and her husband in the emergency room, and barely caught her husband before he hit the floor in a dead faint.

Within hours, the patient was in the ICU, under the care of a whole team. Within days she had begun fairly radical chemotherapy. Within a day or so of that, her organs began to collapse like a house of cards.

My patient wound up on dialysis, on a respirator, in a coma. Some of this was due to her illness, some due to the treatment of her illness, and some due to the treatment of the illnesses resulting from the treatment of her illness. Chemotherapy, for instance, may lead to infection, which leads to antibiotics, which causes colitis, and so on. A patient with respiratory failure needs sedation to remain calm on a respirator, and then one of the reasons for needing the respirator may be the lingering effects of sedatives in a patient with malfunctioning liver and kidneys. It gets murky after a while.

Days dragged by, and my patient’s coma persisted. It started to look as if she might be in a vegetative state from which she would never recover. An EEG was not encouraging. Somewhere along the line, the oncologist decided it was time to throw in the towel.

I disagreed, emphatically. But don’t get me wrong. Far more often over the years, I have gone the other way — telling a family that death is not the ultimate enemy, and comfort should be the priority. Sometimes, a mind is truly gone, and not coming back. Futile gestures are not heroic — and if they add to pain or diminish dignity, they are the very opposite.

But I felt very differently in this case, and challenged the oncologist. The result was a tantrum right in the ICU, culminating with the oncologist telling me: “If you want to take over this case, go right ahead.” And with that, he left — not just the ICU, but the care of the patient.

I did take over. And leaving out the additional days of uncertainty and anguish, the patient recovered. The last I heard from her, she was in complete remission, with all her marbles, and living in Florida.

The new study used functional MRI scans to show that some patients have mental responses to questions their bodies simply cannot display. By looking directly at the brain activity underlying thoughts, the body is no longer a necessary middle man. I did not have the benefit of this technology those years ago at the bedside of my patient. Why did I decide this patient deserved more time, since it wasn’t based on cutting edge technology?

When someone who is chronically ill, very frail, very old, very debilitated — or any combination of these — goes into a coma because of some new malady, one can predict with considerable confidence that things will not go well. The sicker you are to begin with, the less likely recovery is — because your body lacks resilience.

Similarly, some pathology — such as a massive stroke or serious brain trauma — makes a coma predictably ominous. Here we have a clear mechanism to account for permanent brain injury.

But, when someone perfectly intact suddenly loses consciousness due to a bolt from the blue — such as acute leukemia and induction chemotherapy — there is every reason to hope, if not expect, that the former level of functioning can be restored.

I have been amazed many times over the years how easily old, frail and debilitated people have let go of life. But I have been equally amazed at how tenaciously previously healthy people have clung to life, and recovery, against all odds.

So it was those odds I played when I insisted on hanging in there with my patient. I am very glad I did. I’m pretty sure she and her husband were, too.

We can’t always tell the difference, of course, between a mind that is intact but veiled, and a mind that is gone. And the new study is as disturbing as it is enlightening — suggesting how deceptive the veil of unconsciousness may be.

Use your mind logically, lovingly, thoughtfully and thoroughly to part the veil of consciousness and judge what might be going on in the hidden brain of a loved one in peril. Part the veil thoughtfully and then decide if it is, or isn’t, time to throw in the towel.

Contact Dr. David L. Katz at www.davidkatzmd.com.

URL: http://www.nhregister.com/articles/2010/02/15/life/doc4b789b04a99d7520025232.prt

[Bub]

We had in a small town near the city I live in, a case where when the plug was pulled he began breathing on his own and he did "wake up" 20 years later.  He has slowly recovered although still in a wheel chair and can not speak clearly.  The doctors had declared him brain dead years ago. Makes a difficult decision even harder doesn't it?

[monrein]

We had in a small town near the city I live in, a case where when the plug was pulled he began breathing on his own and he did "wake up" 20 years later.  He has slowly recovered although still in a wheel chair and can not speak clearly.  The doctors had declared him brain dead years ago. Makes a difficult decision even harder doesn't it?

I'm curious about what people would choose for themselves in this situation you mention, Bub.  As for me, I feel quite sure that I'd rather die that be in a coma for 20 years only to wake up and be in a wheelchair not speaking clearly.  I personally would find it a dreadful waste of money to be maintained for that long in a state of suspended animation.
Having said that, we can go around knocking people off and I'm sure that others would choose differently for themselves than I would.  I'd find it impossible to decide this for someone else but I personally would rather my family grieve, hopefully remember me fondly and get on with the business of life.  That's why I believe so strongly in the importance of advanced directives....my chance to make my wishes known and to have an idea about how those near and dear to me feel about these things for themselves also.